MEDICARE: KYMBRENA DINETIA JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1285377275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYMBRENA DINETIA JOHNSON

Provider Business Mailing Address
First Line	:	PO BOX 35514
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44135-0514
Country	:	US
Telephone Number	:	419-295-2929
Fax Number	:

Provider Business Practice Location Address
First Line	:	693 E 131ST ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-2034
Country	:	US
Telephone Number	:	419-295-2929
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2022
Last Update Date	:	04/30/2022

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