Basic Information
| Provider Information | |||||||||
| NPI: | 1780216002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 294 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444600294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2345673079 | ||||||||
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| Practice Location | |||||||||
| Address1: | 964 N MARKET ST | ||||||||
| Address2: | |||||||||
| City: | LISBON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444329363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304241468 | ||||||||
| FaxNumber: | 3304241787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2020 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 104984 | OH | N | Nursing Service Providers | Licensed Practical Nurse | 171M00000X | 172735 | OH | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.