MEDICARE: MISS KIMBERLY SUE NOLL LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	17758	OH

General Provider Information

NPI Number	:	1609159318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KIMBERLY SUE NOLL LMT

Provider Business Mailing Address
First Line	:	8066 W SUGAR GROVE RD
Second Line	:
City	:	COVINGTON
State	:	OH
Zip	:	45318-9712
Country	:	US
Telephone Number	:	937-609-0845
Fax Number	:	937-473-3974

Provider Business Practice Location Address
First Line	:	8066 W SUGAR GROVE RD
Second Line	:
City	:	COVINGTON
State	:	OH
Zip	:	45318-9712
Country	:	US
Telephone Number	:	937-609-0845
Fax Number	:	937-473-3974

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2011
Last Update Date	:	09/20/2011

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