Provider Demographics
NPI:1275672628
Name:JOHNSON, KIMBERLY R (CRNA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:ISLE OF PALMS
Mailing Address - State:SC
Mailing Address - Zip Code:29451-2369
Mailing Address - Country:US
Mailing Address - Phone:843-886-6960
Mailing Address - Fax:877-561-7564
Practice Address - Street 1:9263 MEDICAL PLAZA DR
Practice Address - Street 2:STE E
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-7112
Practice Address - Country:US
Practice Address - Phone:843-572-1228
Practice Address - Fax:877-561-7564
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC58367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0561Medicaid
SCAN0561Medicaid