Provider Demographics
NPI:1114474434
Name:WILSON, KIMBERLEY A (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CREEKVIEW CT
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40165-8945
Mailing Address - Country:US
Mailing Address - Phone:502-939-8564
Mailing Address - Fax:
Practice Address - Street 1:6 CREEKVIEW CT
Practice Address - Street 2:
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-8945
Practice Address - Country:US
Practice Address - Phone:502-939-8564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-02
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006920208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation