Provider Demographics
NPI:1851739205
Name:JOHNSON, KIM (RN)
Entity Type:Individual
Prefix:
First Name:KIM
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 1:310 N COLONIAL RDG
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-1633
Mailing Address - Country:US
Mailing Address - Phone:856-273-1832
Mailing Address - Fax:
Practice Address - Street 1:310 N COLONIAL RDG
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-1633
Practice Address - Country:US
Practice Address - Phone:856-273-1832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR05727600163W00000X
NJ10117364174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No163W00000XNursing Service ProvidersRegistered Nurse