Provider Demographics
NPI:1083257786
Name:KIMBALL, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 HERCULES DR STE 110
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-8049
Mailing Address - Country:US
Mailing Address - Phone:802-448-9787
Mailing Address - Fax:802-448-9787
Practice Address - Street 1:173 SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4636
Practice Address - Country:US
Practice Address - Phone:866-476-1321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT6714044Medicaid
VT055.0031689OtherVT STATE LICENSE - PA