Basic Information
| Provider Information | |||||||||
| NPI: | 1306375050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTICE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | EVE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHILLING | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | EVE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 434 EASTLAND RD | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440171217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402608327 | ||||||||
| FaxNumber: | 4402348319 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 TUSCARAWAS ST W STE 501 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447022045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402606466 | ||||||||
| FaxNumber: | 3304381748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2017 | ||||||||
| LastUpdateDate: | 06/07/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | 333839 | OH | Y | Nursing Service Providers | Registered Nurse | Community Health |
No ID Information.