Provider Demographics
NPI:1558904862
Name:KAVULLA, KIMBERLY R (CNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:KAVULLA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6847 N CHESTNUT ST STE 210
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3929
Mailing Address - Country:US
Mailing Address - Phone:330-297-6060
Mailing Address - Fax:216-201-7846
Practice Address - Street 1:6847 N CHESTNUT ST STE 210
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3929
Practice Address - Country:US
Practice Address - Phone:330-297-6060
Practice Address - Fax:216-201-7846
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025730363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner