Provider Demographics
NPI:1952069700
Name:KIMBALL, CARLA LYNN
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:LYNN
Last Name:KIMBALL
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 1:6616 MISTY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-1847
Mailing Address - Country:US
Mailing Address - Phone:916-470-4182
Mailing Address - Fax:
Practice Address - Street 1:6616 MISTY CREEK DR
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-1847
Practice Address - Country:US
Practice Address - Phone:916-470-4182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA