Provider Demographics
NPI:1033117932
Name:KIMBALL, SANDRA L (CNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 BYERS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3684
Mailing Address - Country:US
Mailing Address - Phone:937-866-2494
Mailing Address - Fax:937-866-8494
Practice Address - Street 1:415 BYERS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342
Practice Address - Country:US
Practice Address - Phone:937-866-2494
Practice Address - Fax:937-866-8494
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2021-01-19
Deactivation Date:2006-06-08
Deactivation Code:
Reactivation Date:2006-11-30
Provider Licenses
StateLicense IDTaxonomies
OHNP07739363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2504927Medicaid
OHNP77542Medicare ID - Type Unspecified
OHNP77541Medicare ID - Type Unspecified
OH2504927Medicaid
OHQ23065Medicare UPIN