Provider Demographics
NPI:1154055689
Name:JOHNSON, KIMBERLY DAWN (LPN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 SPARGURSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:45612-9727
Mailing Address - Country:US
Mailing Address - Phone:740-835-1286
Mailing Address - Fax:
Practice Address - Street 1:114 RENICK AVE
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-2879
Practice Address - Country:US
Practice Address - Phone:833-762-1013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.163926.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1154055689Medicaid