Provider Demographics
NPI:1437590031
Name:RIST, KIMBERLY ANN (NP-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:RIST
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 LEXINGTON GLEN BLVD
Mailing Address - Street 2:
Mailing Address - City:MONCLOVA
Mailing Address - State:OH
Mailing Address - Zip Code:43542
Mailing Address - Country:US
Mailing Address - Phone:419-740-2503
Mailing Address - Fax:
Practice Address - Street 1:6546 WEATHERFIELD COURT
Practice Address - Street 2:UNIT D
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537
Practice Address - Country:US
Practice Address - Phone:419-491-6333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF06131131363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily