Provider Demographics
NPI:1255940698
Name:JOHNSON, KIMBERLY RENEE (EP)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:EP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5645 DANVERS RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3730
Mailing Address - Country:US
Mailing Address - Phone:804-368-9767
Mailing Address - Fax:
Practice Address - Street 1:5645 DANVERS RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3730
Practice Address - Country:US
Practice Address - Phone:804-368-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA901698244224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA901698244OtherACSM - AMERICAN COLLEGE OF SPORTS MEDICINE