Provider Demographics
NPI:1467503961
Name:TUNGATE, KIMBERLY DAWN (LPN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:TUNGATE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 S MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:LOUDONVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44842-1406
Mailing Address - Country:US
Mailing Address - Phone:419-994-1919
Mailing Address - Fax:
Practice Address - Street 1:241 S MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:LOUDONVILLE
Practice Address - State:OH
Practice Address - Zip Code:44842-1406
Practice Address - Country:US
Practice Address - Phone:419-994-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN109455164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2606853Medicaid