Provider Demographics
NPI:1679546865
Name:JOHNSON, KIMBERLY MARIE (FNP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 SOUTH STATE STREET
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:24 FRANK LLOYD WRIGHT DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9484
Practice Address - Country:US
Practice Address - Phone:734-998-6022
Practice Address - Fax:734-998-9139
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704207635363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4830324-10Medicaid
MI5008657390OtherBCBS
MI5008657390OtherBCBS
MI4830324-10Medicaid
MI0N99350Medicare ID - Type Unspecified099
MI0N99350002Medicare PIN