Provider Demographics
NPI:1699382432
Name:MASSIE, KIMBERLY SUE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:MASSIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7695 POE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2552
Mailing Address - Country:US
Mailing Address - Phone:937-280-2000
Mailing Address - Fax:
Practice Address - Street 1:7695 POE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-2552
Practice Address - Country:US
Practice Address - Phone:937-280-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN298052163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid