Provider Demographics
NPI:1063731248
Name:JOHNSON, KIMBERLY GREENWOOD (AUDIOLOGIST)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GREENWOOD
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AUDIOLOGIST
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:GREENWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP - PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:653 W 8TH ST
Practice Address - Street 2:UFJAX - DEPT. OF SURGERY/OTOLARYNGOLOGY
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-7463
Practice Address - Fax:904-244-7730
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1591231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0024601-00Medicaid
GA694050310AMedicaid
FLDK564ZMedicare PIN
FLP00947468Medicare PIN