Provider Demographics
NPI:1780828343
Name:RUSSELL, KIMBERLY SUE (NURSE/LPN)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:SUE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NURSE/LPN
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:SUE
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE/LPN
Mailing Address - Street 1:1453 COMMONWEALTH DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-4801
Mailing Address - Country:US
Mailing Address - Phone:937-239-0663
Mailing Address - Fax:
Practice Address - Street 1:81 RHOADS CENTER DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-3859
Practice Address - Country:US
Practice Address - Phone:937-435-1161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN109782164W00000X
OH109782164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2586867Medicaid