Healthcare Provider Details

I. General information

NPI: 1164523221
Provider Name (Legal Business Name): KIMBERLY ANN GREENWALT LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY ANN KARR LPN

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E N AVE CLAY MEDICAL CENTER
FLORA IL
62839
US

IV. Provider business mailing address

PO BOX 155 REA CLINIC
CHRISTOPHER IL
62822
US

V. Phone/Fax

Practice location:
  • Phone: 618-662-8386
  • Fax: 618-662-4338
Mailing address:
  • Phone: 618-724-2401
  • Fax: 618-724-2571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: