Provider Demographics
NPI:1962066548
Name:CLEMENS, KIMBERLY SUE (LPN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:SUE
Other - Last Name:OVERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9880 N 77TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-6667
Mailing Address - Country:US
Mailing Address - Phone:623-486-6479
Mailing Address - Fax:
Practice Address - Street 1:9880 N 77TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-6667
Practice Address - Country:US
Practice Address - Phone:623-486-6479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP054127164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse