Provider Demographics
NPI:1225004328
Name:DETLEF, KIMBERLY JEAN (LPN)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:JEAN
Last Name:DETLEF
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:JEAN
Other - Last Name:DETLEF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:624 BERRY ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43605-2621
Mailing Address - Country:US
Mailing Address - Phone:419-810-7796
Mailing Address - Fax:
Practice Address - Street 1:624 BERRY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43605-2621
Practice Address - Country:US
Practice Address - Phone:419-810-7796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 086382164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse