Provider Demographics
NPI:1437218856
Name:KIMBALL, NICOLE ATHENA (MS PT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ATHENA
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 N 3RD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:406-570-0535
Mailing Address - Fax:
Practice Address - Street 1:1313 W PARK STREET
Practice Address - Street 2:SUITE # 7
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047
Practice Address - Country:US
Practice Address - Phone:406-222-5519
Practice Address - Fax:406-222-0366
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1877225100000X
NY0193081225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00122746OtherRAILROAD MEDICARE
MT60503OtherBLUE CROSS BLUE SHIELD
MT3400826Medicaid
MTMSF1250520OtherMT STATE FUND
P00122746OtherRAILROAD MEDICARE