Provider Demographics
NPI:1952660524
Name:CLARK, KIMBERLY JO (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JO
Last Name:CLARK
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 1:334 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-1153
Mailing Address - Country:US
Mailing Address - Phone:330-328-8920
Mailing Address - Fax:
Practice Address - Street 1:334 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203-1153
Practice Address - Country:US
Practice Address - Phone:330-328-8920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN105573-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse