Provider Demographics
NPI:1578874335
Name:KIMPLE, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:KIMPLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3912
Mailing Address - Country:US
Mailing Address - Phone:601-354-7866
Mailing Address - Fax:601-354-6866
Practice Address - Street 1:931 HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3912
Practice Address - Country:US
Practice Address - Phone:601-354-7866
Practice Address - Fax:601-354-6866
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-27
Last Update Date:2010-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS32005166376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06979709Medicaid