Provider Demographics
NPI:1659116523
Name:KIMBALL, ALICIA
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 GILFORD AVE
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03246-2834
Mailing Address - Country:US
Mailing Address - Phone:603-619-8260
Mailing Address - Fax:
Practice Address - Street 1:40 BEACON ST E
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-3437
Practice Address - Country:US
Practice Address - Phone:603-524-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH077414-21390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program