Healthcare Provider Details

I. General information

NPI: 1780301853
Provider Name (Legal Business Name): DIANA KIMBAL NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 HARRY S TRUMAN DR N
LARGO MD
20774-5477
US

IV. Provider business mailing address

10714 NORMAN AVE
FAIRFAX VA
22030-2931
US

V. Phone/Fax

Practice location:
  • Phone: 240-677-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number0001236200
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberAC005391
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: