Provider Demographics
NPI:1720690035
Name:MCCLENDON, KIMBERLY TAWANA
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:TAWANA
Last Name:MCCLENDON
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 1:628 CASCADE RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-3943
Mailing Address - Country:US
Mailing Address - Phone:513-673-9179
Mailing Address - Fax:513-586-0204
Practice Address - Street 1:628 CASCADE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-3943
Practice Address - Country:US
Practice Address - Phone:513-673-9179
Practice Address - Fax:513-586-0204
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRH860645172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver