Provider Demographics
NPI:1083685275
Name:DEVINE-JOHNSON, KIMBERLY K (RPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
Last Name:DEVINE-JOHNSON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 ST. ANDREWS COURT
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-388-5437
Mailing Address - Fax:507-388-2108
Practice Address - Street 1:150 ST. ANDREWS COURT
Practice Address - Street 2:SUITE 310
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-388-5437
Practice Address - Fax:507-388-2108
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN163T3DEOtherBCBS INDIV PROVIDER #
MN6403767OtherMEDICA INDIV PROVIDER #