Provider Demographics
NPI:1215336466
Name:KIMBERLY, MILDRED
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:KIMBERLY
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 1:59 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44507-1140
Mailing Address - Country:US
Mailing Address - Phone:330-743-8218
Mailing Address - Fax:330-743-8218
Practice Address - Street 1:59 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44507-1140
Practice Address - Country:US
Practice Address - Phone:330-743-8218
Practice Address - Fax:330-743-8218
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH219-88-58374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide