Provider Demographics
NPI:1710386982
Name:ROGERS, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ROGERS
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 1:1950 STATE ROUTE 45 N
Mailing Address - Street 2:
Mailing Address - City:ROCK CREEK
Mailing Address - State:OH
Mailing Address - Zip Code:44084-9795
Mailing Address - Country:US
Mailing Address - Phone:440-897-4670
Mailing Address - Fax:
Practice Address - Street 1:1950 STATE ROUTE 45 N
Practice Address - Street 2:
Practice Address - City:ROCK CREEK
Practice Address - State:OH
Practice Address - Zip Code:44084-9795
Practice Address - Country:US
Practice Address - Phone:440-897-4670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156591164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse