Provider Demographics
NPI:1114926698
Name:WALLACE, KIMBERLY (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 BAINBRIDGE ST
Mailing Address - Street 2:453 LOWER INDIAN HEAD ROAD
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1568
Mailing Address - Country:US
Mailing Address - Phone:215-629-3837
Mailing Address - Fax:215-629-5531
Practice Address - Street 1:420 BAINBRIDGE ST
Practice Address - Street 2:453 LOWER INDIAN HEAD ROAD
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1568
Practice Address - Country:US
Practice Address - Phone:215-629-3837
Practice Address - Fax:215-629-5531
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007970L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA039025SAVMedicare PIN