Provider Demographics
NPI:1053173393
Name:JOHNSON, KIMBERLY LAWAYNE (RN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LAWAYNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35042-4307
Mailing Address - Country:US
Mailing Address - Phone:205-340-4690
Mailing Address - Fax:
Practice Address - Street 1:405 BELCHER ST
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:AL
Practice Address - Zip Code:35042-2946
Practice Address - Country:US
Practice Address - Phone:205-926-2992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-189125163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse