=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821696683
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY ANN KIMBALL DC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2020
-----------------------------------------------------
Last Update Date | 01/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 WISCONSIN AVE NW STE 345
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20007-3680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-743-4104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 WISCONSIN AVE NW STE 345
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20007-3680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-743-4104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0104557640
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH030221
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------