Healthcare Provider Details

I. General information

NPI: 1821320656
Provider Name (Legal Business Name): KIMBERLY SANDERS JOHNSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9430 PARK WEST BLVD # 130
KNOXVILLE TN
37923-4200
US

IV. Provider business mailing address

PO BOX 32569
KNOXVILLE TN
37930-2569
US

V. Phone/Fax

Practice location:
  • Phone: 865-690-4861
  • Fax: 865-560-8252
Mailing address:
  • Phone: 865-694-0062
  • Fax: 865-694-7907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberTEMPORARY PERMIT
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0000001820
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: