Provider Demographics
NPI:1407298698
Name:WALLER, KIMBERLY MICHELLE (LPN)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:WALLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:4707 N MALDEN ST
Mailing Address - Street 2:APT 303
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-6917
Mailing Address - Country:US
Mailing Address - Phone:312-975-3312
Mailing Address - Fax:
Practice Address - Street 1:4707 N MALDEN ST
Practice Address - Street 2:APT 303
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-6917
Practice Address - Country:US
Practice Address - Phone:312-975-3312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043120655164W00000X
OH128873164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse