Healthcare Provider Details

I. General information

NPI: 1548154115
Provider Name (Legal Business Name): KIMBERLY L CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 MAYHAM RD NE
CARROLLTON OH
44615-9130
US

IV. Provider business mailing address

4141 MAYHAM RD NE
CARROLLTON OH
44615-9130
US

V. Phone/Fax

Practice location:
  • Phone: 330-418-8794
  • Fax: 330-418-8794
Mailing address:
  • Phone: 330-418-8794
  • Fax: 330-418-8794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: