Basic Information
| Provider Information | |||||||||
| NPI: | 1629630165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | NE'SHA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HANKSTON | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | NE'SHA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 58 SUMMER ST APT 2 | ||||||||
| Address2: | |||||||||
| City: | HYDE PARK | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021361546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014419128 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 119 WINDSOR ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021393647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176653600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2019 | ||||||||
| LastUpdateDate: | 07/04/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LN97069 | MA | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.