Individual
MS. KIMESHIA NICOLE JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP-C
Contact information
Practice address
5414 S BROADWAY AVE, TYLER, TX 75703-1335
(903) 581-1601
(903) 581-1638
Mailing address
PO BOX 841656, DALLAS, TX 75284-1656
(903) 531-5000
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
679053
TX
363LF0000X
Family Nurse Practitioner
679053
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0031BV
BCBS BLUE
TX
01
—
00T71U
BCBS BLUE
TX
05
—
323946901
—
TX
05
—
323946902
—
TX
01
—
75-0818167-022
TRICARE
TX
01
—
75-2616977-001
TRICARE
TX
01
—
75-2616977-002
TRICARE
TX
01
—
75-2616977-028
TRICARE
TX
01
—
P01246227
RAIL ROAD
TX
01
—
P01304442
RAIL ROAD
TX
Enumeration date
11/03/2008
Last updated
10/13/2014
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