Provider Demographics
NPI:1699226902
Name:KIMBLE, CHERISE
Entity Type:Individual
Prefix:
First Name:CHERISE
Middle Name:
Last Name:KIMBLE
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 1:14128 WINTHROP ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-2143
Mailing Address - Country:US
Mailing Address - Phone:313-516-2881
Mailing Address - Fax:
Practice Address - Street 1:14128 WINTHROP ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2143
Practice Address - Country:US
Practice Address - Phone:313-516-2881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$Medicaid