Healthcare Provider Details

I. General information

NPI: 1083257786
Provider Name (Legal Business Name): NICOLE KIMBALL PA-C, CAQ-OBGYN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 SAINT PAUL ST
BURLINGTON VT
05401-4636
US

IV. Provider business mailing address

784 HERCULES DR STE 110
COLCHESTER VT
05446-8049
US

V. Phone/Fax

Practice location:
  • Phone: 866-476-1321
  • Fax:
Mailing address:
  • Phone: 802-448-9787
  • Fax: 802-448-9787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055.0031689
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA59084
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: