Provider Demographics
NPI:1356792451
Name:PHILLIPS, KIMBERLEY (RN BSN)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4355 ORANGEBERRY DR
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-7912
Mailing Address - Country:US
Mailing Address - Phone:614-493-7970
Mailing Address - Fax:
Practice Address - Street 1:4355 ORANGEBERRY DR
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-7912
Practice Address - Country:US
Practice Address - Phone:614-493-7970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.309932163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice