Provider Demographics
NPI:1114959103
Name:JOHNSON, KIMA (FNP)
Entity Type:Individual
Prefix:
First Name:KIMA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N SUMMIT ST FL 7
Mailing Address - Street 2:HCR MANORCARE MEDICAL SERVICES OF FLORIDA LLC
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-2615
Mailing Address - Country:US
Mailing Address - Phone:419-252-6018
Mailing Address - Fax:800-564-5952
Practice Address - Street 1:916 E LEWIS ST
Practice Address - Street 2:HEARTLAND CARE PARTNERS
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-1699
Practice Address - Country:US
Practice Address - Phone:419-252-6018
Practice Address - Fax:800-564-5952
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJK133105207Q00000X
MI4704133105363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4338002 TYPE 11Medicaid
MI500F410070OtherBCBS
MIP50302Medicare UPIN
MI0N92310 001Medicare ID - Type Unspecified
MI500024152Medicare ID - Type UnspecifiedRAILROAD MEDICARE