Provider Demographics
NPI:1013148584
Name:WALLACE, KIMMY SUE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KIMMY
Middle Name:SUE
Last Name:WALLACE
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 1:735 MARIETTA RD SE
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:OH
Mailing Address - Zip Code:43107-9785
Mailing Address - Country:US
Mailing Address - Phone:740-503-5982
Mailing Address - Fax:
Practice Address - Street 1:735 MARIETTA RD SE
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:OH
Practice Address - Zip Code:43107-9785
Practice Address - Country:US
Practice Address - Phone:740-503-5982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-02
Last Update Date:2009-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN115800164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse