Provider Demographics
NPI:1780662809
Name:KIMBALL, LAURIE A (APRN)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:A
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:LAURIE
Other - Middle Name:A
Other - Last Name:OSDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:264 N MAIN ST
Mailing Address - Street 2:STE 7
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-1815
Mailing Address - Country:US
Mailing Address - Phone:413-525-5080
Mailing Address - Fax:413-525-5070
Practice Address - Street 1:264 N MAIN ST
Practice Address - Street 2:STE 7
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-1815
Practice Address - Country:US
Practice Address - Phone:413-525-5080
Practice Address - Fax:413-525-5070
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN195400261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000767402Medicare PIN