Provider Demographics
NPI:1083358279
Name:EGAN, KIMBERLY R
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:EGAN
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 1:11121 EVERBLADES PKWY APT 203
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-9545
Mailing Address - Country:US
Mailing Address - Phone:732-948-2009
Mailing Address - Fax:
Practice Address - Street 1:12181 FGCU LAKE PKWY E
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33965-6500
Practice Address - Country:US
Practice Address - Phone:732-948-2009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-24
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program