Provider Demographics
NPI:1174057855
Name:KIMBALL, HOLLY ELAINE (AGPCNP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:ELAINE
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 S 31ST ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76508-0001
Mailing Address - Country:US
Mailing Address - Phone:254-215-0100
Mailing Address - Fax:
Practice Address - Street 1:1605 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-4709
Practice Address - Country:US
Practice Address - Phone:254-215-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133825364S00000X, 364SG0600X
TX713761364S00000X
TX1108466363LP2300X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology