Provider Demographics
NPI:1598413064
Name:KIMBALL, KELLY MARIE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:KIMBALL
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 1:4209 STATE ROUTE 44
Mailing Address - Street 2:
Mailing Address - City:ROOTSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44272-9698
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4209 STATE ROUTE 44
Practice Address - Street 2:
Practice Address - City:ROOTSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44272-9698
Practice Address - Country:US
Practice Address - Phone:800-686-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-14
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH57.254633207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program