Healthcare Provider Details

I. General information

NPI: 1730141797
Provider Name (Legal Business Name): KIMBERLY ERIN JOHNSON MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY ERIN BOENU MSPT

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 OLD ORCHARD SQ
ELLIJAY GA
30540-8172
US

IV. Provider business mailing address

8823 PRODUCTION LN
OOLTEWAH TN
37363-6511
US

V. Phone/Fax

Practice location:
  • Phone: 706-273-3131
  • Fax: 706-273-3133
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-954-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01895
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT011319
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: