Provider Demographics
NPI:1790384188
Name:KIMBLE, PORSHAE (ADULT FAMILY HOME)
Entity Type:Individual
Prefix:
First Name:PORSHAE
Middle Name:
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:ADULT FAMILY HOME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4428 W LLOYD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-1207
Mailing Address - Country:US
Mailing Address - Phone:414-395-3360
Mailing Address - Fax:
Practice Address - Street 1:4428 W LLOYD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1207
Practice Address - Country:US
Practice Address - Phone:414-395-3360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-18
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30311376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide