Basic Information
| Provider Information | |||||||||
| NPI: | 1528089505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIMMEL | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1023 E CHERRY ST STE A | ||||||||
| Address2: | |||||||||
| City: | CUSHING | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740234105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182250771 | ||||||||
| FaxNumber: | 9182251993 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 HERITAGE CIR | ||||||||
| Address2: | |||||||||
| City: | PAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740583744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187622517 | ||||||||
| FaxNumber: | 9187624614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 11/20/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 17678 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100195080C | 05 | OK | MEDICAID |