Provider Demographics
NPI:1174335012
Name:KIMBLE, ANGELIQUE (PTA)
Entity type:Individual
Prefix:MRS
First Name:ANGELIQUE
Middle Name:
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 W MAIN RD APT 2504
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-6392
Mailing Address - Country:US
Mailing Address - Phone:407-486-1612
Mailing Address - Fax:
Practice Address - Street 1:309 SPRING ST # 2
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-6858
Practice Address - Country:US
Practice Address - Phone:401-849-3204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPTA01210225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant