Provider Demographics
NPI:1114264348
Name:NOLEN, KIMBERLY S (OT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:NOLEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 720610
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-0610
Mailing Address - Country:US
Mailing Address - Phone:601-346-9191
Mailing Address - Fax:601-346-5011
Practice Address - Street 1:7213 S SIWELL RD
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-9776
Practice Address - Country:US
Practice Address - Phone:601-346-9191
Practice Address - Fax:601-346-5011
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist