MEDICARE: KIMBERLY MARY JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374T00000X	Religious Nonmedical Nursing Personnel

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1194752873	OTHER	TX	THE LEAVES PROVIDER IDENTIFIER NUMBER

General Provider Information

NPI Number	:	1922437102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY MARY JOHNSON

Provider Business Mailing Address
First Line	:	1230 W SPRING VALLEY RD
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75080-7709
Country	:	US
Telephone Number	:	972-643-3527
Fax Number	:

Provider Business Practice Location Address
First Line	:	1230 W SPRING VALLEY RD
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75080-7709
Country	:	US
Telephone Number	:	972-643-3527
Fax Number	:	972-643-3500

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2013
Last Update Date	:	11/07/2013

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Directions to “ KIMBERLY MARY JOHNSON ” Practice Location

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