Healthcare Provider Details

I. General information

NPI: 1730811324
Provider Name (Legal Business Name): KIMBERLY WAN JOHNSTON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1590
US

IV. Provider business mailing address

35 E WHEELING ST
BALTIMORE MD
21230-4029
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR228785
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR228785
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: