Provider Demographics
NPI:1710594098
Name:KIMBALL, KAITLYN MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:KIMBALL
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 1:510 S EAST AVE
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:OH
Mailing Address - Zip Code:43543-1616
Mailing Address - Country:US
Mailing Address - Phone:260-920-0128
Mailing Address - Fax:
Practice Address - Street 1:510 S EAST AVE
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:OH
Practice Address - Zip Code:43543-1616
Practice Address - Country:US
Practice Address - Phone:260-920-0128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.164076.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse