Provider Demographics
NPI:1245887447
Name:DIEL, KIMBERLY LYNN (AGACNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:DIEL
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 VISION PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77384-3023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:129 VISION PARK BLVD STE 307
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3024
Practice Address - Country:US
Practice Address - Phone:369-321-5440
Practice Address - Fax:936-271-3707
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAPP144254363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX805026OtherNA