MEDICARE: KIMBERLY JO TODD LPN

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	164W00000X	Licensed Practical Nurse	PN-099006	OH

General Provider Information

NPI Number	:	1790913184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY JO TODD LPN

Provider Business Mailing Address
First Line	:	164 WILSON ST
Second Line	:
City	:	PORTSMOUTH
State	:	OH
Zip	:	45662-5779
Country	:	US
Telephone Number	:	740-876-4599
Fax Number	:

Provider Business Practice Location Address
First Line	:	164 WILSON ST
Second Line	:
City	:	PORTSMOUTH
State	:	OH
Zip	:	45662-5779
Country	:	US
Telephone Number	:	740-876-4599
Fax Number	:

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

Provider Enumeration Date	:	06/24/2009
Last Update Date	:	12/19/2012

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