Healthcare Provider Details

I. General information

NPI: 1982993473
Provider Name (Legal Business Name): KIMBERLY LANE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 FLEMING ROAD
LORETTO TN
38469
US

IV. Provider business mailing address

PO BOX 165
LORETTO TN
38469-0165
US

V. Phone/Fax

Practice location:
  • Phone: 931-853-6872
  • Fax:
Mailing address:
  • Phone: 931-853-6872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: