Provider Demographics
NPI:1154638542
Name:GOODNITE, KIMBERLY A (LMT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:GOODNITE
Suffix:
Gender:F
Credentials:LMT
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 699
Mailing Address - Street 2:
Mailing Address - City:PECATONICA
Mailing Address - State:IL
Mailing Address - Zip Code:61063-0699
Mailing Address - Country:US
Mailing Address - Phone:815-239-1121
Mailing Address - Fax:815-239-2766
Practice Address - Street 1:427 MAIN ST
Practice Address - Street 2:
Practice Address - City:PECATONICA
Practice Address - State:IL
Practice Address - Zip Code:61063-7737
Practice Address - Country:US
Practice Address - Phone:815-239-1121
Practice Address - Fax:815-239-2766
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227011185225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist