Provider Demographics
NPI:1053943340
Name:CHANEY, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:CHANEY
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 1:418 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HUBBARD
Mailing Address - State:OH
Mailing Address - Zip Code:44425-2277
Mailing Address - Country:US
Mailing Address - Phone:888-424-0094
Mailing Address - Fax:888-424-0094
Practice Address - Street 1:68 BUHL BLVD
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:PA
Practice Address - Zip Code:16146-3706
Practice Address - Country:US
Practice Address - Phone:888-424-0094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1924515171W00000X
PAPA016151171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0357697Medicaid