Provider Demographics
NPI:1699734103
Name:PROCELL, KIMBERLY (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:PROCELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 RUSSELL BLVD
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1247
Mailing Address - Country:US
Mailing Address - Phone:936-564-1740
Mailing Address - Fax:
Practice Address - Street 1:615 RUSSELL BLVD
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1247
Practice Address - Country:US
Practice Address - Phone:936-564-1740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1298208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1748857-01Medicaid
TX00M37MTOtherBLUE CROSS