Provider Demographics
NPI:1497130678
Name:JOHNSON, KIMBERLY (RN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 LOUDOUN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3218
Mailing Address - Country:US
Mailing Address - Phone:757-673-4476
Mailing Address - Fax:757-673-4818
Practice Address - Street 1:3706 PRINCETON PL
Practice Address - Street 2:I-3
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-2450
Practice Address - Country:US
Practice Address - Phone:757-673-4476
Practice Address - Fax:757-673-4814
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001229913163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse