Provider Demographics
NPI:1730141797
Name:JOHNSON, KIMBERLY ERIN (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ERIN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:ERIN
Other - Last Name:BOENU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-954-7408
Practice Address - Street 1:190 OLD ORCHARD SQ
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-8172
Practice Address - Country:US
Practice Address - Phone:706-273-3131
Practice Address - Fax:706-273-3133
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI01895225100000X
GAPT011319225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI412111OtherBLUE CHIP
1133771OtherAETNA
RI29777OtherNEIGHBORHOOD HEALTH
RI297789OtherBCBS
GAPT011319OtherPHYSICAL THERAPIST
709003312OtherMEDICARE PTAN
RI080001895RI01OtherANTHEM