Provider Demographics
NPI:1033668926
Name:SHELTON, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SHELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 US 20A
Mailing Address - Street 2:
Mailing Address - City:SWANTON
Mailing Address - State:OH
Mailing Address - Zip Code:43558-9801
Mailing Address - Country:US
Mailing Address - Phone:419-490-8320
Mailing Address - Fax:
Practice Address - Street 1:1919 US 20A
Practice Address - Street 2:
Practice Address - City:SWANTON
Practice Address - State:OH
Practice Address - Zip Code:43558-9801
Practice Address - Country:US
Practice Address - Phone:419-490-8320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0050632376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050632Medicaid