Provider Demographics
NPI:1376315622
Name:ROSS, KIMBERLY CAROL
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CAROL
Last Name:ROSS
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 1:9720 S PULASKI RD APT 105
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3322
Mailing Address - Country:US
Mailing Address - Phone:773-655-9401
Mailing Address - Fax:
Practice Address - Street 1:9720 S PULASKI RD APT 105
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3322
Practice Address - Country:US
Practice Address - Phone:773-655-9401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide