MEDICARE: KIMBERLY MARLENE JOHNSTON

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	156FX1800X	Optician	1867	GA

General Provider Information

NPI Number	:	1457180044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY MARLENE JOHNSTON

Provider Business Mailing Address
First Line	:	4365 ATLANTA HWY
Second Line	:
City	:	ATHENS
State	:	GA
Zip	:	30606-0808
Country	:	US
Telephone Number	:	706-548-2824
Fax Number	:	706-548-2481

Provider Business Practice Location Address
First Line	:	4365 ATLANTA HWY
Second Line	:
City	:	ATHENS
State	:	GA
Zip	:	30606-0808
Country	:	US
Telephone Number	:	706-548-2824
Fax Number	:	706-548-2481

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

Provider Enumeration Date	:	07/31/2024
Last Update Date	:	07/31/2024

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Directions to “ KIMBERLY MARLENE JOHNSTON ” Practice Location

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