1164523221 NPI number — MRS. KIMBERLY ANN GREENWALT LPN

Table of content: MRS. KIMBERLY ANN GREENWALT LPN (NPI 1164523221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164523221 NPI number — MRS. KIMBERLY ANN GREENWALT LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENWALT
Provider First Name:
KIMBERLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
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:
KARR
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164523221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 155
Provider Second Line Business Mailing Address:
REA CLINIC
Provider Business Mailing Address City Name:
CHRISTOPHER
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-724-2401
Provider Business Mailing Address Fax Number:
618-724-2571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 E N AVE
Provider Second Line Business Practice Location Address:
CLAY MEDICAL CENTER
Provider Business Practice Location Address City Name:
FLORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-662-8386
Provider Business Practice Location Address Fax Number:
618-662-4338
Provider Enumeration Date:
09/25/2006

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 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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