Basic Information
| Provider Information | |||||||||
| NPI: | 1073993317 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUNDRIDGE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 KOLBE RD | ||||||||
| Address2: | PALLIATIVE CARE DEPT | ||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409341458 | ||||||||
| FaxNumber: | 4409604922 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 KOLBE RD | ||||||||
| Address2: | PALLIATIVE CARE DEPT | ||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409341458 | ||||||||
| FaxNumber: | 4409604922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2015 | ||||||||
| LastUpdateDate: | 09/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA .17589-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0207207 | 05 | OH | MEDICAID |