Provider Demographics
NPI:1720685829
Name:KIMBLE, JUDY ANN
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:ANN
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 DILLON SCHOOL DR
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-9628
Mailing Address - Country:US
Mailing Address - Phone:740-995-3089
Mailing Address - Fax:
Practice Address - Street 1:3020 DILLON SCHOOL DR
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-9628
Practice Address - Country:US
Practice Address - Phone:740-995-3089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376J00000X, 374U00000X
OH6002309376J00000X
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6002309OtherOHIO
OH6002309Medicaid