Provider Demographics
NPI:1699928655
Name:JOHNSON, KIMESHIA NICOLE (FNP-C)
Entity type:Individual
Prefix:MS
First Name:KIMESHIA
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:5414 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1335
Practice Address - Country:US
Practice Address - Phone:903-581-1601
Practice Address - Fax:903-581-1638
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX679053363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-001OtherTRICARE
TXP01246227OtherRAIL ROAD
TXP01304442OtherRAIL ROAD
TX323946901Medicaid
TX0031BVOtherBCBS BLUE
TX75-0818167-022OtherTRICARE
TX00T71UOtherBCBS BLUE
TX75-2616977-002OtherTRICARE
TX75-2616977-028OtherTRICARE
TX323946902Medicaid
TX294214YNSXMedicare PIN
TXP01246227OtherRAIL ROAD