Provider Demographics
NPI:1427212976
Name:KIMBELL, REBECCA ELAINE (MSN, APRN, CNP)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:ELAINE
Last Name:KIMBELL
Suffix:
Gender:F
Credentials:MSN, APRN, CNP
Other - Prefix:MRS
Other - First Name:REBECCA
Other - Middle Name:ELAINE
Other - Last Name:KIMBELL-FARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, APRN, CNP
Mailing Address - Street 1:801 KIDWELL DR
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:MO
Mailing Address - Zip Code:65084-1787
Mailing Address - Country:US
Mailing Address - Phone:573-378-5454
Mailing Address - Fax:573-378-5055
Practice Address - Street 1:801 KIDWELL DR
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:MO
Practice Address - Zip Code:65084-1787
Practice Address - Country:US
Practice Address - Phone:573-378-5454
Practice Address - Fax:573-378-5055
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0063706363LF0000X
MO2013009202363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1427212976Medicaid
MO135570059OtherMEDICARE PTAN
OK200205320AMedicaid
OKOK401270Medicare PIN
OK200205320AMedicaid