Provider Demographics
NPI:1568183846
Name:KIMBERLY NICHELSON DPM
Entity Type:Organization
Organization Name:KIMBERLY NICHELSON DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:NICHELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:419-750-0041
Mailing Address - Street 1:108 TRAILHEAD LN
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1099
Mailing Address - Country:US
Mailing Address - Phone:419-750-0041
Mailing Address - Fax:
Practice Address - Street 1:630 E RIVER ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-5902
Practice Address - Country:US
Practice Address - Phone:419-750-0041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH36.003767OtherSTATE LICENSE