Provider Demographics
NPI:1114532520
Name:GAFFNEY, KIMMI SUE
Entity Type:Individual
Prefix:MRS
First Name:KIMMI
Middle Name:SUE
Last Name:GAFFNEY
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 1:7650 WITHERSPOON DR NE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:OH
Mailing Address - Zip Code:43105-9712
Mailing Address - Country:US
Mailing Address - Phone:740-407-5546
Mailing Address - Fax:
Practice Address - Street 1:7650 WITHERSPOON DR NE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:OH
Practice Address - Zip Code:43105-9712
Practice Address - Country:US
Practice Address - Phone:740-407-5546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2304965374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1050008644499Medicaid