Provider Demographics
NPI:1073993317
Name:BUNDRIDGE, KIMBERLY JEAN (CNP)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:JEAN
Last Name:BUNDRIDGE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 KOLBE RD
Mailing Address - Street 2:PALLIATIVE CARE DEPT
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1632
Mailing Address - Country:US
Mailing Address - Phone:440-934-1458
Mailing Address - Fax:440-960-4922
Practice Address - Street 1:3500 KOLBE RD
Practice Address - Street 2:PALLIATIVE CARE DEPT
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1632
Practice Address - Country:US
Practice Address - Phone:440-934-1458
Practice Address - Fax:440-960-4922
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA .17589-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0207207Medicaid
OHH384641Medicare PIN
OH9288887Medicare PIN