Provider Demographics
NPI:1134324916
Name:JOHNSON, KIMBERLY LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 TRUXTON AVE
Mailing Address - Street 2:
Mailing Address - City:FT WALTON BCH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-2460
Mailing Address - Country:US
Mailing Address - Phone:850-974-6518
Mailing Address - Fax:850-863-1765
Practice Address - Street 1:119 TRUXTON AVE
Practice Address - Street 2:
Practice Address - City:FT WALTON BCH
Practice Address - State:FL
Practice Address - Zip Code:32547-2460
Practice Address - Country:US
Practice Address - Phone:850-974-6518
Practice Address - Fax:850-863-1765
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31011174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist