Provider Demographics
NPI:1326709742
Name:KIMBALL, KATHERINE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:GARDELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:240 S MAIN ST STE H
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03894-4411
Mailing Address - Country:US
Mailing Address - Phone:603-569-7690
Mailing Address - Fax:605-569-7664
Practice Address - Street 1:240 S MAIN ST STE H
Practice Address - Street 2:
Practice Address - City:WOLFEBORO
Practice Address - State:NH
Practice Address - Zip Code:03894-4411
Practice Address - Country:US
Practice Address - Phone:603-569-7690
Practice Address - Fax:603-569-7664
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2487363A00000X, 363A00000X, 363AM0700X
NH2119363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPA2487OtherMAINE BOARD OF LICENSURE IN MEDICINE