Provider Demographics
NPI:1962663450
Name:JOHNSON, KIMENITA ROSUNDA (INDIVIDUAL PROVIDER)
Entity type:Individual
Prefix:MS
First Name:KIMENITA
Middle Name:ROSUNDA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:INDIVIDUAL PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14961 TYLER ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-7640
Mailing Address - Country:US
Mailing Address - Phone:786-486-6855
Mailing Address - Fax:305-688-1415
Practice Address - Street 1:14961 TYLER ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-7640
Practice Address - Country:US
Practice Address - Phone:786-486-6855
Practice Address - Fax:305-688-1415
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL230621172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230621OtherHOMEMAKER &COMPANION SERVICES