Kimberly Lane Wallace, NP-C

Primary specialty

Primary Care Nurse PractitionerTaxonomy code 363LP2300X

License

APRN.CNP.0032777 Issued in OH

Practice address

3535 Pentagon Blvd
Beavercreek, OH 45431-1705

Phone

(937) 702-4000

NPI assigned

Dec 6, 2022

Last updated

Dec 6, 2022By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in OH

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Nephrology Associates of Dayton Inc

  • Nephrology Physician
  • Dayton, OH
  • NPI 1184698458
  Medicare reassignment NPD
• Renal Physicians Inc

  dba Dayton Kidney

  • Nephrology Physician
  • Kettering, OH
  • NPI 1962486316
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1670284800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1670284800000",
    "number": "1619688116",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "935 SALEM ST",
            "city": "BROOKVILLE",
            "state": "OH",
            "postal_code": "453098225",
            "telephone_number": "937-344-5173"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3535 PENTAGON BLVD",
            "city": "BEAVERCREEK",
            "state": "OH",
            "postal_code": "454311705",
            "telephone_number": "937-702-4000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "KIMBERLY",
        "middle_name": "LANE",
        "credential": "NP-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-12-06",
        "last_updated": "2022-12-06",
        "certification_date": "2022-12-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP2300X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Primary Care",
            "state": "OH",
            "license": "APRN.CNP.0032777",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Wal-Mart Stores East, LP (Vision Center 30-2124)
• Gordon S Walbroehl, MD
• Walgreen Co (Walgreens #11510)
• Laurie Walker Hoff, MS, PCC
• Kenyana Walker
• Jessica Wallen
• Abby Walls, LPCC-S
• Grace Walters
• Takojia D. Walters, LPCC
• Christine Marie Walton, PHARMD

• Primary Care Nurse Practitioner in Beavercreek, OH
• Providers in Beavercreek, OH by specialty
• Primary Care Nurse Practitioner in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 6, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.