Healthcare Provider Details

I. General information

NPI: 1225232010
Provider Name (Legal Business Name): MRS. KIMBERLY JANELL JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 MARTIN WAY
OWENSBORO KY
42301-8619
US

IV. Provider business mailing address

193 MARTIN WAY
OWENSBORO KY
42301-8619
US

V. Phone/Fax

Practice location:
  • Phone: 270-683-3381
  • Fax: 270-683-3381
Mailing address:
  • Phone: 270-314-5353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: