Provider Demographics
NPI:1275204232
Name:BLAIR, KIMBERLY LERAE (STNA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LERAE
Last Name:BLAIR
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LERAE
Other - Last Name:TACKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:STNA
Mailing Address - Street 1:110 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-1208
Mailing Address - Country:US
Mailing Address - Phone:740-477-1745
Mailing Address - Fax:
Practice Address - Street 1:110 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-1208
Practice Address - Country:US
Practice Address - Phone:740-477-1745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH321737930905376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide