Provider Demographics
NPI:1629763164
Name:HENNIGAN, KIMBERLY RENEE
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:RENEE
Last Name:HENNIGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:RENEE
Other - Last Name:CLEARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:492 DIAMOND CT
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-1119
Mailing Address - Country:US
Mailing Address - Phone:330-558-0084
Mailing Address - Fax:
Practice Address - Street 1:492 DIAMOND CT
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-1119
Practice Address - Country:US
Practice Address - Phone:440-570-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH253Z00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No253Z00000XAgenciesIn Home Supportive Care