Provider Demographics
NPI:1033455571
Name:UNDERWOOD, KIMBERLY ANN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6103 JESSAMINE LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-2437
Mailing Address - Country:US
Mailing Address - Phone:502-935-1352
Mailing Address - Fax:
Practice Address - Street 1:1550 RAYDALE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-5031
Practice Address - Country:US
Practice Address - Phone:502-968-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01447225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant