Basic Information
| Provider Information | |||||||||
| NPI: | 1699928655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KIMESHIA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5414 S BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757031335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035811601 | ||||||||
| FaxNumber: | 9035811638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2008 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 679053 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 679053 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 75-2616977-001 | 01 | TX | TRICARE | OTHER | P01246227 | 01 | TX | RAIL ROAD | OTHER | P01304442 | 01 | TX | RAIL ROAD | OTHER | 323946901 | 05 | TX | MEDICAID | 0031BV | 01 | TX | BCBS BLUE | OTHER | 75-0818167-022 | 01 | TX | TRICARE | OTHER | 00T71U | 01 | TX | BCBS BLUE | OTHER | 75-2616977-002 | 01 | TX | TRICARE | OTHER | 75-2616977-028 | 01 | TX | TRICARE | OTHER | 323946902 | 05 | TX | MEDICAID |