Provider Demographics
NPI:1225280886
Name:CLARK, KIMBERLEY ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLEY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:ANN
Other - Last Name:BRHEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:68 PRINCETON LN
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-9027
Mailing Address - Country:US
Mailing Address - Phone:585-598-3092
Mailing Address - Fax:
Practice Address - Street 1:5415 COUNTY ROAD 30
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-7964
Practice Address - Country:US
Practice Address - Phone:585-394-9510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist