Provider Demographics
NPI:1760609499
Name:OHL, KIM (NP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:OHL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 HEALTH CENTER DR STE 101
Mailing Address - Street 2:SBL WEIGHT MANAGEMENT
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-4774
Mailing Address - Fax:217-238-4775
Practice Address - Street 1:1005 HEALTH CENTER DR STE 101
Practice Address - Street 2:SBL WEIGHT MANAGEMENT
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4693
Practice Address - Country:US
Practice Address - Phone:217-238-4774
Practice Address - Fax:217-238-4775
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001743363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6447860004Medicare NSC
ILIL3270324Medicare PIN