Provider Demographics
NPI:1043526460
Name:JOHNSON, KIMBERLY CRUMP (NP-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CRUMP
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JAYNE
Other - Last Name:CRUMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1297
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-7297
Mailing Address - Country:US
Mailing Address - Phone:478-624-3213
Mailing Address - Fax:478-627-3669
Practice Address - Street 1:2809 PINE ST
Practice Address - Street 2:
Practice Address - City:UNADILLA
Practice Address - State:GA
Practice Address - Zip Code:31091-7701
Practice Address - Country:US
Practice Address - Phone:478-627-3213
Practice Address - Fax:478-627-3669
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN093193363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003120293AMedicaid
GA003120293AMedicaid