Provider Demographics
NPI:1689764821
Name:GREEN, KIMBERLE K (LPN)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLE
Middle Name:K
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18809 HARLAN DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-2239
Mailing Address - Country:US
Mailing Address - Phone:216-662-0791
Mailing Address - Fax:216-662-0791
Practice Address - Street 1:18809 HARLAN DR
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-2239
Practice Address - Country:US
Practice Address - Phone:216-662-0791
Practice Address - Fax:216-662-0791
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN088729164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse