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General NPI Number Information
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NPI Number | 1144046145
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Entity Type | Individual
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Provider Name | KIMBERLY RENEE GULLATT
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Gender | Female
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Dates
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Enumeration Date | 11/25/2024
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Last Update Date | 11/25/2024
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Provider Practice Location Address
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Address Line | 38599 FAIRWAY GLENN BLVD
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City | WILLOUGHBY
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State | OH
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Zip | 44094-7180
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Country | US
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Telephone | 216-409-7045
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Fax |
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Provider Business Mailing Address
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Address Line | 38599 FAIRWAY GLENN BLVD
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City | WILLOUGHBY
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State | OH
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Zip | 44094-7180
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Country | US
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Telephone | 216-409-7045
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | LPN.168.104-IV
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License Number State | OH
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