Provider Demographics
NPI:1619913738
Name:VANDEGRIFT, KIMBERLY A (RN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:VANDEGRIFT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 PORTAGE ST NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-2353
Mailing Address - Country:US
Mailing Address - Phone:330-417-3283
Mailing Address - Fax:509-351-9739
Practice Address - Street 1:1101 PORTAGE ST NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-2353
Practice Address - Country:US
Practice Address - Phone:330-417-3283
Practice Address - Fax:509-351-9739
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-243460163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2313375Medicaid