Healthcare Provider Details

I. General information

NPI: 1033117932
Provider Name (Legal Business Name): SANDRA L KIMBALL CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date: 06/08/2006
Reactivation Date: 11/30/2006

III. Provider practice location address

415 BYERS RD SUITE 300
MIAMISBURG OH
45342
US

IV. Provider business mailing address

415 BYERS RD STE 300
MIAMISBURG OH
45342-3684
US

V. Phone/Fax

Practice location:
  • Phone: 937-866-2494
  • Fax: 937-866-8494
Mailing address:
  • Phone: 937-866-2494
  • Fax: 937-866-8494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP07739
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN.CNP.07739
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: