Healthcare Provider Details

I. General information

NPI: 1972014553
Provider Name (Legal Business Name): HERMAN KIMBALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 S DUKE ST
DURHAM NC
27701-3975
US

IV. Provider business mailing address

807 S DUKE ST
DURHAM NC
27701-3975
US

V. Phone/Fax

Practice location:
  • Phone: 919-596-5386
  • Fax: 919-680-2955
Mailing address:
  • Phone: 919-596-5386
  • Fax: 919-680-2955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number249835
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: