Basic Information
| Provider Information | |||||||||
| NPI: | 1558645291 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIMBLE | ||||||||
| FirstName: | KELSEY | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 W CARLETON RD | ||||||||
| Address2: | |||||||||
| City: | HILLSDALE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492425034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172128140 | ||||||||
| FaxNumber: | 5172128141 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177485500 | ||||||||
| FaxNumber: | 5177832728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2011 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601006175 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 5601006175 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.