Provider Demographics
NPI:1134710015
Name:KIMANI, JOHNMICHAEL TUMBO
Entity type:Individual
Prefix:
First Name:JOHNMICHAEL
Middle Name:TUMBO
Last Name:KIMANI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 W BROADWAY STE 200
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-2323
Mailing Address - Country:US
Mailing Address - Phone:508-484-3034
Mailing Address - Fax:
Practice Address - Street 1:230 AMHERST ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-1702
Practice Address - Country:US
Practice Address - Phone:508-484-3034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2309715363LP0808X
NH086555-23363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health