Provider Demographics
NPI:1558645291
Name:KIMBLE, KELSEY (PAC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W CARLETON RD
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-5034
Mailing Address - Country:US
Mailing Address - Phone:517-212-8140
Mailing Address - Fax:517-212-8141
Practice Address - Street 1:505 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1266
Practice Address - Country:US
Practice Address - Phone:517-748-5500
Practice Address - Fax:517-783-2728
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006175363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical