Provider Demographics
NPI:1265040224
Name:WADDLE, KINLEY MARIE (MED)
Entity Type:Individual
Prefix:
First Name:KINLEY
Middle Name:MARIE
Last Name:WADDLE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5782 GLOXINIA CT
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-9352
Mailing Address - Country:US
Mailing Address - Phone:614-634-8370
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:4664 LARWELL DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3621
Practice Address - Country:US
Practice Address - Phone:614-487-7805
Practice Address - Fax:614-487-7809
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2023-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH106S00000X
OHRBT-20-128263106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician