Provider Demographics
NPI:1316129836
Name:KIMBLE, JOHNNA L (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JOHNNA
Middle Name:L
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-3803
Mailing Address - Country:US
Mailing Address - Phone:505-445-7090
Mailing Address - Fax:505-445-7663
Practice Address - Street 1:323 S 5TH ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NM
Practice Address - Zip Code:88415-2641
Practice Address - Country:US
Practice Address - Phone:505-374-9313
Practice Address - Fax:505-374-8844
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4186235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64075362Medicaid