Provider Demographics
NPI:1730150889
Name:JOHNSON, KIMBERLY A (APRN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-3190
Mailing Address - Country:US
Mailing Address - Phone:757-736-3725
Mailing Address - Fax:757-431-7782
Practice Address - Street 1:100 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23692-3190
Practice Address - Country:US
Practice Address - Phone:757-736-3725
Practice Address - Fax:757-431-7782
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO138414363LF0000X
VA0024177320363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1730150889Medicaid
MOP01230388OtherRR MEDICARE
MO138414OtherRN FNPC LICENSE NUMBER
MO701000209Medicare PIN