Provider Demographics
NPI:1538521562
Name:MOWRY, KIMBERLY L (LPN, QMHS)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:MOWRY
Suffix:
Gender:F
Credentials:LPN, QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:NEW LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43764-9511
Mailing Address - Country:US
Mailing Address - Phone:740-342-5154
Mailing Address - Fax:740-588-6452
Practice Address - Street 1:915 S RIVERSIDE DR NE
Practice Address - Street 2:
Practice Address - City:MCCONNELSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43756-9102
Practice Address - Country:US
Practice Address - Phone:740-962-5204
Practice Address - Fax:740-962-3688
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHPN153688 M IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0185304Medicaid