Provider Demographics
NPI:1801928908
Name:MOCK, KIMBERLY M
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:MOCK
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 1:420 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-9566
Mailing Address - Country:US
Mailing Address - Phone:440-428-6236
Mailing Address - Fax:
Practice Address - Street 1:420 RIVER ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-9566
Practice Address - Country:US
Practice Address - Phone:440-428-6236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2591833OtherDYSERV