Provider Demographics
NPI:1639701147
Name:BREAZELL, KIMBLE
Entity Type:Individual
Prefix:
First Name:KIMBLE
Middle Name:
Last Name:BREAZELL
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 1:4133 BAY RUM LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-6333
Mailing Address - Country:US
Mailing Address - Phone:719-439-1571
Mailing Address - Fax:
Practice Address - Street 1:702 N PERSON ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1216
Practice Address - Country:US
Practice Address - Phone:919-626-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC5252374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide