Basic Information
| Provider Information | |||||||||
| NPI: | 1164024253 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIMBALL | ||||||||
| FirstName: | KELSEY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 NEWBERRY RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326072245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523366013 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4500 W NEWBERRY RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523366000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2020 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9113627 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.