Provider Demographics
NPI:1730959180
Name:JOHNSON, KIMBERLY DIANE (RADIOLOGIC TECHNOLOG)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RADIOLOGIC TECHNOLOG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72936-9171
Mailing Address - Country:US
Mailing Address - Phone:479-719-5842
Mailing Address - Fax:
Practice Address - Street 1:2711 WATSON RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:AR
Practice Address - Zip Code:72936-9171
Practice Address - Country:US
Practice Address - Phone:479-719-5842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5394282471C3401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography