Provider Demographics
NPI:1073214862
Name:KIMBLE, ALETHIA JULIANNA (AMSA)
Entity Type:Individual
Prefix:
First Name:ALETHIA
Middle Name:JULIANNA
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:AMSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 W WEBSTER ST APT 5
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1481
Mailing Address - Country:US
Mailing Address - Phone:618-218-1145
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:618-997-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other