MEDICARE: KIMBERLY ERMALOVICH FNP

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	207Q00000X	Family Medicine Physician	4028830	KY
2	363LF0000X	Family Nurse Practitioner	4028830	KY

General Provider Information

NPI Number	:	1790504371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY ERMALOVICH FNP

Provider Business Mailing Address
First Line	:	1001 4TH ST E
Second Line	:
City	:	SOUTH POINT
State	:	OH
Zip	:	45680-9120
Country	:	US
Telephone Number	:	304-654-9010
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 4TH ST E
Second Line	:
City	:	SOUTH POINT
State	:	OH
Zip	:	45680-9120
Country	:	US
Telephone Number	:	304-654-9010
Fax Number	:

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

Provider Enumeration Date	:	10/09/2024
Last Update Date	:	12/05/2024

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