Healthcare Provider Details

I. General information

NPI: 1649748310
Provider Name (Legal Business Name): KIMBERLY LEE BROCKLEHURST CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2018
Last Update Date: 10/12/2024
Certification Date: 10/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 ALLENTOWN RD
LIMA OH
45805-1705
US

IV. Provider business mailing address

2195 ALLENTOWN RD
LIMA OH
45805-1705
US

V. Phone/Fax

Practice location:
  • Phone: 419-227-2245
  • Fax: 419-229-1573
Mailing address:
  • Phone: 419-227-2245
  • Fax: 419-229-1573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number313177
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberARRN.CNP.024119
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAPRN.CNP.024119
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.024119
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: