Provider Demographics
NPI:1255607867
Name:KIMMEL, TRACIE LEIGH (RN)
Entity type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:LEIGH
Last Name:KIMMEL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:COLSTRIP
Mailing Address - State:MT
Mailing Address - Zip Code:59323-0213
Mailing Address - Country:US
Mailing Address - Phone:406-748-3473
Mailing Address - Fax:
Practice Address - Street 1:100 CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:LAME DEER
Practice Address - State:MT
Practice Address - Zip Code:59043-0070
Practice Address - Country:US
Practice Address - Phone:406-477-8848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT44899163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse