Provider Demographics
NPI:1033406830
Name:WIECHMANN, KIMBERLY ROSE (DPT)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ROSE
Last Name:WIECHMANN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W125 OOSTY AVE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-5532
Mailing Address - Country:US
Mailing Address - Phone:262-424-0267
Mailing Address - Fax:
Practice Address - Street 1:15751 SAN CARLOS BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3314
Practice Address - Country:US
Practice Address - Phone:339-237-3729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11809-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist