Provider Demographics
NPI:1700548526
Name:KIMBLE, TERRI DIANE
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:DIANE
Last Name:KIMBLE
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 1:31223 ALICE LN
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-4057
Mailing Address - Country:US
Mailing Address - Phone:832-444-3286
Mailing Address - Fax:
Practice Address - Street 1:31223 ALICE LN
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-4057
Practice Address - Country:US
Practice Address - Phone:832-444-3286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1056567208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice