Provider Demographics
NPI:1356836647
Name:KIMBLE, OLIVIA (FNP)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:OLIVERA
Other - Middle Name:
Other - Last Name:VELICKOVIC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:
Practice Address - Street 1:4129 S MEADOWS RD APT 424
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3066
Practice Address - Country:US
Practice Address - Phone:505-639-9476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM53443363L00000X
NMF06180294363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily