Provider Demographics
NPI:1245388859
Name:JOHNSON, KIMBERLY WADDELL
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:WADDELL
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 1:4230 NC HIGHWAY 18 S
Mailing Address - Street 2:
Mailing Address - City:MORAVIAN FALLS
Mailing Address - State:NC
Mailing Address - Zip Code:28654-9833
Mailing Address - Country:US
Mailing Address - Phone:336-921-3361
Mailing Address - Fax:
Practice Address - Street 1:910 C ST
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-4145
Practice Address - Country:US
Practice Address - Phone:336-667-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist