Provider Demographics
NPI:1649748310
Name:BROCKLEHURST, KIMBERLY LEE (CNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LEE
Last Name:BROCKLEHURST
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4332
Mailing Address - Country:US
Mailing Address - Phone:192-213-0724
Mailing Address - Fax:
Practice Address - Street 1:1550 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-2823
Practice Address - Country:US
Practice Address - Phone:419-549-5982
Practice Address - Fax:419-225-8878
Is Sole Proprietor?:No
Enumeration Date:2018-11-11
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH313177163WE0003X
OHARRN.CNP.024119208000000X
OHAPRN.CNP.024119208000000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPRN.CNP.024119OtherCERTFIED NURSE PRACTITIONER
OHAPRN.CNP.024119OtherCERTIFIED NURSE PRACTITIONER
OH3131777OtherREGISTEREC NURSE