Provider Demographics
NPI:1720402100
Name:PETERSON, KIMBERLY (RN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11300 COLUMBIANA CANFIELD RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-8485
Mailing Address - Country:US
Mailing Address - Phone:330-549-5578
Mailing Address - Fax:330-549-3430
Practice Address - Street 1:11300 COLUMBIANA CANFIELD RD
Practice Address - Street 2:SUITE E
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-8485
Practice Address - Country:US
Practice Address - Phone:330-549-5578
Practice Address - Fax:330-549-3430
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN201768163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse