Provider Demographics
NPI:1306673553
Name:KIMBLE, SHIRLEY
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
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 1:1241 HIGHWAY 1 S
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-6444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 POND STREET EXT
Practice Address - Street 2:
Practice Address - City:DODDSVILLE
Practice Address - State:MS
Practice Address - Zip Code:38736
Practice Address - Country:US
Practice Address - Phone:662-402-6884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906327363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology