Provider Demographics
NPI:1083143036
Name:KIMBLE, LISA NICOLE
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:NICOLE
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27273 HIGHWAY 100
Mailing Address - Street 2:
Mailing Address - City:BUNCH
Mailing Address - State:OK
Mailing Address - Zip Code:74931-2094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-3100
Practice Address - Country:US
Practice Address - Phone:918-797-7786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator