Provider Demographics
NPI:1932173895
Name:JOHNSTON, KIMBERLI S (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLI
Middle Name:S
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLI
Other - Middle Name:S
Other - Last Name:KNIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:3730 7TH TER STE 101
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6556
Practice Address - Country:US
Practice Address - Phone:772-567-2332
Practice Address - Fax:844-812-2806
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1707363A00000X
FLPA9117536363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119014300Medicaid
WI041U 73-601Medicare PIN
WIQ16112Medicare UPIN