Provider Demographics
NPI:1841337110
Name:KIMBALL, TRACI A (MD CWSP)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:A
Last Name:KIMBALL
Suffix:
Gender:
Credentials:MD CWSP
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:M
Other - Last Name:ANGELICA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10050 RALSTON RD UNIT 3
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80004-4974
Mailing Address - Country:US
Mailing Address - Phone:303-940-1611
Mailing Address - Fax:303-432-2296
Practice Address - Street 1:10050 RALSTON RD UNIT 3
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80004-4974
Practice Address - Country:US
Practice Address - Phone:303-940-1611
Practice Address - Fax:303-432-2296
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 171400000X, 171W00000X, 173000000X, 1744R1102X, 174H00000X, 175F00000X, 175L00000X, 246XC2903X, 246ZB0301X
CODR49586208D00000X, 208600000X
CO332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No171W00000XOther Service ProvidersContractor
No173000000XOther Service ProvidersLegal Medicine
No1744R1102XOther Service ProvidersSpecialistResearch Study
No174H00000XOther Service ProvidersHealth Educator
No175F00000XOther Service ProvidersNaturopath
No175L00000XOther Service ProvidersHomeopath
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No246XC2903XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularVascular Specialist
No246ZB0301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherBiomedical Engineering
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98159241Medicaid
CO98159241Medicaid