Provider Demographics
NPI:1942066899
Name:KIMMEL, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KIMMEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26884 CORONATION DR
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48183-5822
Mailing Address - Country:US
Mailing Address - Phone:313-550-9338
Mailing Address - Fax:
Practice Address - Street 1:1355 BOGUE ST
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-6207
Practice Address - Country:US
Practice Address - Phone:517-432-8163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704342349163WS0200X
MI1519070146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic