1407298698 NPI number — MISS KIMBERLY MICHELLE WALLER LPN

Table of content: MISS KIMBERLY MICHELLE WALLER LPN (NPI 1407298698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407298698 NPI number — MISS KIMBERLY MICHELLE WALLER LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLER
Provider First Name:
KIMBERLY
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALLER
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPN
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1407298698
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4707 N MALDEN ST
Provider Second Line Business Mailing Address:
APT 303
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60640-6917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-975-3312
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4707 N MALDEN ST
Provider Second Line Business Practice Location Address:
APT 303
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60640-6917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-975-3312
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  043120655 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 164W00000X , with the licence number: 128873 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)