Healthcare Provider Details

I. General information

NPI: 1942164694
Provider Name (Legal Business Name): RAVEN SEYMONE KIMBRO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2614 PIONEER TRL APT 609
SANDUSKY OH
44870-5188
US

IV. Provider business mailing address

2614 PIONEER TRL APT 609
SANDUSKY OH
44870-5188
US

V. Phone/Fax

Practice location:
  • Phone: 440-654-6528
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number402235311219
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: