Provider Demographics
NPI:1922437102
Name:JOHNSON, KIMBERLY MARY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 W SPRING VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-7709
Mailing Address - Country:US
Mailing Address - Phone:972-643-3527
Mailing Address - Fax:
Practice Address - Street 1:1230 W SPRING VALLEY RD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-7709
Practice Address - Country:US
Practice Address - Phone:972-643-3527
Practice Address - Fax:972-643-3500
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1194752873OtherTHE LEAVES PROVIDER IDENTIFIER NUMBER