Healthcare Provider Details

I. General information

NPI: 1073993317
Provider Name (Legal Business Name): KIMBERLY JEAN BUNDRIDGE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 09/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 KOLBE RD PALLIATIVE CARE DEPT
LORAIN OH
44053-1632
US

IV. Provider business mailing address

3500 KOLBE RD PALLIATIVE CARE DEPT
LORAIN OH
44053-1632
US

V. Phone/Fax

Practice location:
  • Phone: 440-934-1458
  • Fax: 440-960-4922
Mailing address:
  • Phone: 440-934-1458
  • Fax: 440-960-4922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA .17589-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: