Provider Demographics
NPI:1902194293
Name:SCOTT, KIMBERLY ANN (CNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:SCOTT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:RIDDLEBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:335 GLESSNER AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2269
Mailing Address - Country:US
Mailing Address - Phone:419-562-1413
Mailing Address - Fax:
Practice Address - Street 1:1020 CRICKET LN
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-4104
Practice Address - Country:US
Practice Address - Phone:419-526-8877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF0711222363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050310Medicaid
OHMS2428779OtherDEA
OHH037632Medicare PIN