Provider Demographics
NPI:1033855184
Name:JOHNSON, KIMBERLY NOEL
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:NOEL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 KENBROOK CT NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-3521
Mailing Address - Country:US
Mailing Address - Phone:404-435-9940
Mailing Address - Fax:
Practice Address - Street 1:1180 ERNEST W BARRETT PKWY NW # 102B
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4534
Practice Address - Country:US
Practice Address - Phone:678-354-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA119356363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics