Provider Demographics
NPI:1053002949
Name:JOHNSON, KIMA LASHAWN
Entity type:Individual
Prefix:
First Name:KIMA
Middle Name:LASHAWN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 ROYAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-2247
Mailing Address - Country:US
Mailing Address - Phone:330-309-3509
Mailing Address - Fax:
Practice Address - Street 1:2703 38TH ST NW APT H
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-2051
Practice Address - Country:US
Practice Address - Phone:330-309-3509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN01005172A00000X, 385HR2050X
OHRN010005332U00000X, 343900000X, 347C00000X, 376J00000X, 385HR2055X, 385HR2060X, 385HR2065X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No172A00000XOther Service ProvidersDriver
No332U00000XSuppliersHome Delivered Meals
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No376J00000XNursing Service Related ProvidersHomemaker
No385HR2050XRespite Care FacilityRespite CareRespite Care Camp
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child