Provider Demographics
NPI:1336657279
Name:KIMBLE, SIDNEY SHEYENNE (BS)
Entity Type:Individual
Prefix:MISS
First Name:SIDNEY
Middle Name:SHEYENNE
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 N JONES AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2215
Mailing Address - Country:US
Mailing Address - Phone:918-207-2192
Mailing Address - Fax:
Practice Address - Street 1:1429 JACK BROWN LANE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-316-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator