Healthcare Provider Details

I. General information

NPI: 1437610573
Provider Name (Legal Business Name): KIMBERLY JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20126 STANTON AVE STE 200
CASTRO VALLEY CA
94546-5270
US

IV. Provider business mailing address

747 52ND ST
OAKLAND CA
94609-1809
US

V. Phone/Fax

Practice location:
  • Phone: 510-881-4210
  • Fax:
Mailing address:
  • Phone: 510-881-4210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA178634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: