Provider Demographics
NPI:1053772293
Name:HENCKEL INZANO, KIMBERLEY
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:HENCKEL INZANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37755 LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:EASTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44095-1051
Mailing Address - Country:US
Mailing Address - Phone:440-278-0427
Mailing Address - Fax:
Practice Address - Street 1:37755 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:EASTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44095-1051
Practice Address - Country:US
Practice Address - Phone:440-278-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH198439163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse