Healthcare Provider Details

I. General information

NPI: 1922390749
Provider Name (Legal Business Name): MAUREEN G HOLMGREN NIMMO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 DARNELL RD
BENTON KY
42025-6903
US

IV. Provider business mailing address

867 DARNELL RD
BENTON KY
42025-6903
US

V. Phone/Fax

Practice location:
  • Phone: 270-205-6624
  • Fax: 270-933-4031
Mailing address:
  • Phone: 270-205-6624
  • Fax: 270-933-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number500128
License Number StateKY

VIII. Authorized Official

Name: MAUREEN G NIMMO
Title or Position: OWNER
Credential:
Phone: 270-205-6624