Provider Demographics
NPI:1124085303
Name:KIMMEL, HEIDI R (PAC)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:R
Last Name:KIMMEL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:B
Other - Last Name:RIETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:733 CHICAGO DR
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-6448
Mailing Address - Country:US
Mailing Address - Phone:952-892-0434
Mailing Address - Fax:
Practice Address - Street 1:6363 FRANCE AVE S
Practice Address - Street 2:STE 525
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2129
Practice Address - Country:US
Practice Address - Phone:952-926-6489
Practice Address - Fax:952-926-6501
Is Sole Proprietor?:No
Enumeration Date:2006-04-29
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant