Healthcare Provider Details

I. General information

NPI: 1194171801
Provider Name (Legal Business Name): OLIVIA KIMBLE LTM, CPM, MSM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 TRAIL VIEW LN SE
PINE ISLAND MN
55963-8608
US

IV. Provider business mailing address

1001 TRAIL VIEW LN SE
PINE ISLAND MN
55963-8608
US

V. Phone/Fax

Practice location:
  • Phone: 720-982-9530
  • Fax:
Mailing address:
  • Phone: 720-982-9530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number1083
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: