Provider Demographics
NPI:1053647107
Name:KIMBROUGH, MARQUETTA LYNN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARQUETTA
Middle Name:LYNN
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 BARKSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-7413
Mailing Address - Country:US
Mailing Address - Phone:740-389-3859
Mailing Address - Fax:
Practice Address - Street 1:143 BARKSWOOD RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-7413
Practice Address - Country:US
Practice Address - Phone:740-389-3859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN096535164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse