Provider Demographics
NPI:1760820732
Name:KIMBRELL, ASHLEY (MED)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:KIMBRELL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 MONUMENT RD
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-3620
Mailing Address - Country:US
Mailing Address - Phone:580-603-2709
Mailing Address - Fax:
Practice Address - Street 1:1412 MONUMENT RD
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-3620
Practice Address - Country:US
Practice Address - Phone:580-603-2709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS$$$$$$$$$Medicaid