Provider Demographics
NPI:1902325053
Name:THROCKMORTON, KIMBERLY
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:
Last Name:THROCKMORTON
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 1:204 BAIN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-4014
Mailing Address - Country:US
Mailing Address - Phone:740-396-7483
Mailing Address - Fax:
Practice Address - Street 1:204 BAIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-4014
Practice Address - Country:US
Practice Address - Phone:740-396-7483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH159223164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse