Basic Information
| Provider Information | |||||||||
| NPI: | 1053049809 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIMBALL | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855052988 | ||||||||
| FaxNumber: | 7855055228 | ||||||||
| Practice Location | |||||||||
| Address1: | 4525 W 6TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660497700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855508723 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2022 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 53-81349-102 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 30004840230001 | 05 | KS | MEDICAID |