Provider Demographics
NPI:1114616141
Name:NIETO, KIMBERLY JENELLE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JENELLE
Last Name:NIETO
Suffix:
Gender:F
Credentials:PTA
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 720774
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-0774
Mailing Address - Country:US
Mailing Address - Phone:956-994-8505
Mailing Address - Fax:956-994-8586
Practice Address - Street 1:4604 S SUGAR RD APT 821
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-0146
Practice Address - Country:US
Practice Address - Phone:956-358-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2162471225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant