Provider Demographics
NPI:1891062477
Name:ANDERSON, KIMBERLY MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:ANDERSON
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 1:983 RIDGEWAY CT APT A
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-2562
Mailing Address - Country:US
Mailing Address - Phone:513-267-5917
Mailing Address - Fax:
Practice Address - Street 1:983 RIDGEWAY CT APT A
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-2562
Practice Address - Country:US
Practice Address - Phone:513-267-5917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-25
Last Update Date:2011-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH133942-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse