MEDICARE: KIMBERLY 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	332BC3200X	Customized Equipment (DME)
2	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1568116572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY JOHNSON

Provider Business Mailing Address
First Line	:	5370 CAMPBELLTON FAIRBURN RD STE 210
Second Line	:
City	:	FAIRBURN
State	:	GA
Zip	:	30213-0019
Country	:	US
Telephone Number	:	347-546-8100
Fax Number	:

Provider Business Practice Location Address
First Line	:	1115 STERLING PL
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-2606
Country	:	US
Telephone Number	:	347-546-8100
Fax Number	:

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

Provider Enumeration Date	:	02/08/2022
Last Update Date	:	02/08/2022

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Directions to “ KIMBERLY JOHNSON ” Practice Location

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