Provider Demographics
NPI:1124692702
Name:KIMBALL, CASSIDY N (AA)
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:N
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:CASSIDY
Other - Middle Name:N
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA
Mailing Address - Street 1:PO BOX 804408
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-4408
Mailing Address - Country:US
Mailing Address - Phone:913-647-4100
Mailing Address - Fax:913-647-4120
Practice Address - Street 1:2525 GLENN HENDREN DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-9625
Practice Address - Country:US
Practice Address - Phone:816-781-7200
Practice Address - Fax:816-792-7196
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021022736367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO65093015OtherBCBS KC
MO910098763Medicaid