Provider Demographics
NPI:1730370487
Name:KIMBALL, MICHELLE LYNN
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNN
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:BEELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1234
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-8234
Mailing Address - Country:US
Mailing Address - Phone:503-397-5211
Mailing Address - Fax:503-397-5373
Practice Address - Street 1:185 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1535
Practice Address - Country:US
Practice Address - Phone:503-397-5211
Practice Address - Fax:503-397-5373
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR195164Medicaid