Provider Demographics
NPI:1932860103
Name:BOLER, KIMBERLY (LPN, WIG MAKER)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BOLER
Suffix:
Gender:F
Credentials:LPN, WIG MAKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2341 EQUESTRIAN DR APT 1A
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-5629
Mailing Address - Country:US
Mailing Address - Phone:937-663-2971
Mailing Address - Fax:
Practice Address - Street 1:8139 OLD TROY PIKE
Practice Address - Street 2:SUITE #1007
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424
Practice Address - Country:US
Practice Address - Phone:937-663-2971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH138614332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies