Provider Demographics
NPI:1144046145
Name:GULLATT, KIMBERLY RENEE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RENEE
Last Name:GULLATT
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 1:38599 FAIRWAY GLENN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7180
Mailing Address - Country:US
Mailing Address - Phone:216-409-7045
Mailing Address - Fax:
Practice Address - Street 1:38599 FAIRWAY GLENN BLVD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-7180
Practice Address - Country:US
Practice Address - Phone:216-409-7045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
OHLPN.168.104-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No251E00000XAgenciesHome Health