Provider Demographics
NPI:1588717243
Name:KIMBALL, CHANTEL (ATC, OTC)
Entity type:Individual
Prefix:MS
First Name:CHANTEL
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 S BROWNING CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NH
Mailing Address - Zip Code:03275-1329
Mailing Address - Country:US
Mailing Address - Phone:603-321-7803
Mailing Address - Fax:603-627-7638
Practice Address - Street 1:700 LAKE AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-2734
Practice Address - Country:US
Practice Address - Phone:603-669-5454
Practice Address - Fax:603-627-7638
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer