Healthcare Provider Details

I. General information

NPI: 1881099232
Provider Name (Legal Business Name): KIMBERLY NETTLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 ROCKDALE AVE
CINCINNATI OH
45229-2919
US

IV. Provider business mailing address

1324 EVALIE DR
FAIRFIELD OH
45014-3513
US

V. Phone/Fax

Practice location:
  • Phone: 513-357-7382
  • Fax:
Mailing address:
  • Phone: 513-907-2965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number51.011626
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: