Provider Demographics
NPI:1205400520
Name:JOHNSON, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1547 30TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5149
Mailing Address - Country:US
Mailing Address - Phone:218-287-4338
Mailing Address - Fax:
Practice Address - Street 1:1910 AGA DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1796
Practice Address - Country:US
Practice Address - Phone:320-762-0829
Practice Address - Fax:218-287-5928
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist