Provider Demographics
NPI:1720752751
Name:KIMBERLY, MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KIMBERLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-8019
Mailing Address - Country:US
Mailing Address - Phone:503-473-9332
Mailing Address - Fax:
Practice Address - Street 1:209 FRONT ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-2837
Practice Address - Country:US
Practice Address - Phone:318-336-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2576321Medicaid