Provider Demographics
NPI:1881688570
Name:JOHNSON, KIMBERLY ANN (DC)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 OMRO RD
Mailing Address - Street 2:STE A
Mailing Address - City:OSKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7746
Mailing Address - Country:US
Mailing Address - Phone:920-426-4200
Mailing Address - Fax:920-426-3730
Practice Address - Street 1:2210 OMRO RD
Practice Address - Street 2:STE A
Practice Address - City:OSKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7746
Practice Address - Country:US
Practice Address - Phone:920-426-4200
Practice Address - Fax:920-426-3730
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI2589111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38858600Medicaid
WI391850270011OtherBLUE CROSS BLUE SHIELD
WI000035776Medicare ID - Type Unspecified
WI391850270011OtherBLUE CROSS BLUE SHIELD