Provider Demographics
NPI:1609049931
Name:NELSON, KIMM L
Entity Type:Individual
Prefix:MS
First Name:KIMM
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMM
Other - Middle Name:L
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035
Mailing Address - Country:US
Mailing Address - Phone:614-882-5861
Mailing Address - Fax:
Practice Address - Street 1:998 CONE STOGA DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213
Practice Address - Country:US
Practice Address - Phone:614-882-5861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH067046164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH067046OtherLICENSED NURSE OHIO PIN N