Provider Demographics
NPI:1912611005
Name:STUCKE, KIMBERLY ANN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:STUCKE
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 1:1924 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MARIA STEIN
Mailing Address - State:OH
Mailing Address - Zip Code:45860-9811
Mailing Address - Country:US
Mailing Address - Phone:419-305-2600
Mailing Address - Fax:
Practice Address - Street 1:1924 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MARIA STEIN
Practice Address - State:OH
Practice Address - Zip Code:45860-9811
Practice Address - Country:US
Practice Address - Phone:419-305-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA005158224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant