Healthcare Provider Details

I. General information

NPI: 1518272707
Provider Name (Legal Business Name): KIMBERLY L JOHNSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 WELTON WAY
MOORESVILLE NC
28117-9163
US

IV. Provider business mailing address

131 WELTON WAY
MOORESVILLE NC
28117-9163
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-4564
  • Fax: 704-360-4553
Mailing address:
  • Phone: 704-360-4564
  • Fax: 704-360-4553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0709387
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number336144
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5005051
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: