Provider Demographics
NPI:1093896680
Name:KIDNER, KIMBERLY K (DC)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:K
Last Name:KIDNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 N PLUM ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-1817
Mailing Address - Country:US
Mailing Address - Phone:815-844-4631
Mailing Address - Fax:815-844-1942
Practice Address - Street 1:402 N. PLUM ST.
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9786
Practice Address - Country:US
Practice Address - Phone:815-844-4631
Practice Address - Fax:815-844-1942
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008659111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor