Provider Demographics
NPI:1578380523
Name:KIMMEL, MYA NIKKI ANNE
Entity type:Individual
Prefix:
First Name:MYA
Middle Name:NIKKI ANNE
Last Name:KIMMEL
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 1:119 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-2117
Mailing Address - Country:US
Mailing Address - Phone:330-801-2585
Mailing Address - Fax:
Practice Address - Street 1:919 N COURT ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-1501
Practice Address - Country:US
Practice Address - Phone:330-391-7237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.027130225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist