Provider Demographics
NPI:1265870943
Name:KIMBALL, CARRIE LELANIA (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:LELANIA
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 PLUM AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-5815
Mailing Address - Country:US
Mailing Address - Phone:267-456-2129
Mailing Address - Fax:
Practice Address - Street 1:31 PLUM AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-5815
Practice Address - Country:US
Practice Address - Phone:267-456-2129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2023-08-20
Deactivation Date:2023-07-27
Deactivation Code:
Reactivation Date:2023-08-14
Provider Licenses
StateLicense IDTaxonomies
NYF404998-01363LP0808X
PA11116425163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant