Provider Demographics
NPI:1639659378
Name:KIMBLE, ANDIE
Entity Type:Individual
Prefix:
First Name:ANDIE
Middle Name:
Last Name:KIMBLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8477 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5028
Mailing Address - Country:US
Mailing Address - Phone:352-382-1141
Mailing Address - Fax:
Practice Address - Street 1:255 N EGRET BAY BLVD
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6533
Practice Address - Country:US
Practice Address - Phone:352-382-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2096250225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant