Provider Demographics
NPI:1457426058
Name:KIMBLE, DAVID FISHER (RN CNS)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:FISHER
Last Name:KIMBLE
Suffix:
Gender:M
Credentials:RN CNS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:20 STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5618
Mailing Address - Country:US
Mailing Address - Phone:781-874-0592
Mailing Address - Fax:
Practice Address - Street 1:20 RESEARCH PKWY
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-4214
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:860-510-0020
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239643364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1004745OtherNHP
1303287OtherMBHP
703136OtherTUFTS
NP10332OtherBOSTON MED CTR
MACP0110OtherBCBS
MANS045901OtherMEDICARE ID
MA1303287Medicaid
99618201OtherNETWORK HEALTH
MAM18633OtherBCBS
703136OtherTUFTS