Provider Demographics
NPI:1396153201
Name:KIMMEL, JENNIFER MICHELLE RAY (NNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE RAY
Last Name:KIMMEL
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MICHELLE
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3020 CHILDRENS WAY # MC5008
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-966-5818
Mailing Address - Fax:
Practice Address - Street 1:3010 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-966-5818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95001764363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal