Healthcare Provider Details

I. General information

NPI: 1285600437
Provider Name (Legal Business Name): KIMBERLY SUSAN JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 MAGNOLIA CIRCLE
TYNDALL AFB FL
32403-5612
US

IV. Provider business mailing address

1214 HUNTINGTON RIDGE RD
LYNN HAVEN FL
32444-3189
US

V. Phone/Fax

Practice location:
  • Phone: 850-283-7678
  • Fax: 850-283-7620
Mailing address:
  • Phone: 850-814-7987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number024311
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: