Healthcare Provider Details

I. General information

NPI: 1356836647
Provider Name (Legal Business Name): OLIVIA KIMBLE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OLIVERA VELICKOVIC

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SPRUCE ST
ESPANOLA NM
87532-2724
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-367-0340
  • Fax:
Mailing address:
  • Phone: 505-923-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number53443
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06180294
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-4547
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: