MEDICARE: DR. KIMBERLY PROCELL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	M1298	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	00M37MT	OTHER	TX	BLUE CROSS

General Provider Information

NPI Number	:	1699734103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMBERLY PROCELL M.D.

Provider Business Mailing Address
First Line	:	615 RUSSELL BLVD
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1247
Country	:	US
Telephone Number	:	936-564-1740
Fax Number	:

Provider Business Practice Location Address
First Line	:	615 RUSSELL BLVD
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1247
Country	:	US
Telephone Number	:	936-564-1740
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	06/12/2024

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