Provider Demographics
NPI:1902871205
Name:KIMBALL, JENNIFER S (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 BATES ST
Mailing Address - Street 2:STE 102
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240
Mailing Address - Country:US
Mailing Address - Phone:207-783-2300
Mailing Address - Fax:207-783-2439
Practice Address - Street 1:77 BATES ST
Practice Address - Street 2:STE 102
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-783-2300
Practice Address - Fax:207-783-2439
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER045683363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
010424957OtherCHAMPUS
010424957OtherSTANDARD TAX ID
010424957OtherCHAMPUS GROUP NUMBER
010424957OtherSTANDARD TAX ID GROUP
010424957OtherTRICARE GROUP NUMBER
010424957OtherHARVARD PILGRIM GROUP NO
010424957OtherTRICARE
P0061OtherBCBS GROUP NUMBER
010424957OtherEMPLOY STANDARDS
250012128OtherMEDICARE RAILROAD GROUP
010424957OtherAETNA GROUP NUMBER
047308OtherBCBS
P0061OtherBCBS GROUP NUMBER
MM0755Medicare ID - Type UnspecifiedGROUP NUMBER