Provider Demographics
NPI:1255661161
Name:KIMBLE, KELLY ANN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:KIMBLE
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 1:17748 ROCK CREEK RD LOT 46
Mailing Address - Street 2:
Mailing Address - City:THOMPSON
Mailing Address - State:OH
Mailing Address - Zip Code:44086-9762
Mailing Address - Country:US
Mailing Address - Phone:440-298-1315
Mailing Address - Fax:
Practice Address - Street 1:17748 ROCK CREEK RD LOT 46
Practice Address - Street 2:
Practice Address - City:THOMPSON
Practice Address - State:OH
Practice Address - Zip Code:44086-9762
Practice Address - Country:US
Practice Address - Phone:440-298-1315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN338503163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse