Provider Demographics
NPI:1609200625
Name:BALTZELL, KIMBERLY (CNS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BALTZELL
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E APPLE ST
Mailing Address - Street 2:STE 5254A
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2939
Mailing Address - Country:US
Mailing Address - Phone:937-208-4200
Mailing Address - Fax:937-208-4205
Practice Address - Street 1:30 E APPLE ST
Practice Address - Street 2:STE 5254A
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-4200
Practice Address - Fax:937-208-4205
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14740-NS364SA2100X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0091249Medicaid
OHH254200Medicare PIN