Provider Demographics
NPI:1013263235
Name:KIMBRELL, LESLIE ANNE (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:ANNE
Last Name:KIMBRELL
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4852 OLD ALMA RD
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-4521
Mailing Address - Country:US
Mailing Address - Phone:912-337-5588
Mailing Address - Fax:
Practice Address - Street 1:4852 OLD ALMA RD
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-4521
Practice Address - Country:US
Practice Address - Phone:912-337-5588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3555174400000X
GAPT006329174400000X
MA19645174400000X
TX1212716174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist