Healthcare Provider Details

I. General information

NPI: 1174818579
Provider Name (Legal Business Name): KIMBERLY A. TEMPLE APRN, CCNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 W 3RD ST SURGERY (112)
DAYTON OH
45428-9000
US

IV. Provider business mailing address

4100 W 3RD ST SURGERY (112)
DAYTON OH
45428-9000
US

V. Phone/Fax

Practice location:
  • Phone: 937-268-6511
  • Fax: 937-267-3991
Mailing address:
  • Phone: 937-268-6511
  • Fax: 937-267-3991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberRN234672-COA1COA1067
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberRN.234672-COA1 COA.1
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: