=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174057855
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY ELAINE KIMBALL AGPCNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2017
-----------------------------------------------------
Last Update Date | 11/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1605 S 31ST ST
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76508-4709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-215-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1605 S 31ST ST
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76508-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-215-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364S00000X
-----------------------------------------------------
Taxonomy Name | Clinical Nurse Specialist
-----------------------------------------------------
License Number | AP133825
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 364S00000X
-----------------------------------------------------
Taxonomy Name | Clinical Nurse Specialist
-----------------------------------------------------
License Number | 713761
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 1108466
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 1108466
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 364SG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Clinical Nurse Specialist
-----------------------------------------------------
License Number | AP133825
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------