Provider Demographics
NPI:1164633814
Name:KIMBALL, BROOKE ANNETTE (LMP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ANNETTE
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5710 198TH ST SW APT D
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6146
Mailing Address - Country:US
Mailing Address - Phone:425-776-9382
Mailing Address - Fax:425-778-1014
Practice Address - Street 1:9631 FIRDALE AVE
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-6519
Practice Address - Country:US
Practice Address - Phone:206-271-5368
Practice Address - Fax:425-778-1014
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017893174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist