Healthcare Provider Details

I. General information

NPI: 1528089505
Provider Name (Legal Business Name): MICHELLE DAWN KIMMEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 HERITAGE CIR
PAWNEE OK
74058-3744
US

IV. Provider business mailing address

1023 E CHERRY ST STE A
CUSHING OK
74023-4105
US

V. Phone/Fax

Practice location:
  • Phone: 918-762-2517
  • Fax: 918-762-4614
Mailing address:
  • Phone: 918-225-0771
  • Fax: 918-225-1993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17678
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: