Provider Demographics
NPI:1164051850
Name:JOHNSON, KIMBERLY L
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:F
Other - Last Name:EDMONDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14055 46TH STREET NORTH SUITE 1102
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762
Mailing Address - Country:US
Mailing Address - Phone:727-509-4441
Mailing Address - Fax:
Practice Address - Street 1:14055 46TH STREET NORTH SUITE 1102
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762
Practice Address - Country:US
Practice Address - Phone:727-509-4441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No251E00000XAgenciesHome Health