Provider Demographics
NPI:1336308147
Name:GLASS, KIMBERLY N
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:GLASS
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 1:2018 W 103RD ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-3525
Mailing Address - Country:US
Mailing Address - Phone:216-651-1901
Mailing Address - Fax:440-946-2600
Practice Address - Street 1:2018 W 103RD ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-3525
Practice Address - Country:US
Practice Address - Phone:216-651-1901
Practice Address - Fax:440-946-2600
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2583057Medicaid