Provider Demographics
NPI:1679995658
Name:STUTZ, KIMBERLY RAE (CNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RAE
Last Name:STUTZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:RAE
Other - Last Name:POLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6847 N CHESTNUT ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3929
Mailing Address - Country:US
Mailing Address - Phone:330-296-4165
Mailing Address - Fax:330-296-5536
Practice Address - Street 1:6847 N CHESTNUT ST
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3929
Practice Address - Country:US
Practice Address - Phone:330-296-4165
Practice Address - Fax:330-297-8463
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH353026-RN163W00000X
OH15349-NP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse