Provider Demographics
NPI:1275792970
Name:JOHNSON, KIMBERLY NICOLE (MPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:NICOLE
Other - Last Name:HEBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:2000 MEDICAL PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3742
Mailing Address - Country:US
Mailing Address - Phone:410-295-8900
Mailing Address - Fax:410-280-4701
Practice Address - Street 1:2000 MEDICAL PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3742
Practice Address - Country:US
Practice Address - Phone:410-295-8900
Practice Address - Fax:410-280-4701
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22508225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist