Provider Demographics
NPI:1316065147
Name:MITCHELL, KIMBERLY KAY (STNA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KAY
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13483 BEESON ST NE
Mailing Address - Street 2:#2
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601
Mailing Address - Country:US
Mailing Address - Phone:330-823-4911
Mailing Address - Fax:330-823-4911
Practice Address - Street 1:13483 BEESON ST NE
Practice Address - Street 2:SUITE #1
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601
Practice Address - Country:US
Practice Address - Phone:330-823-4911
Practice Address - Fax:330-823-4911
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400237990503376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH400237990503Medicaid
OH400237990503Medicaid