Provider Demographics
NPI:1225377906
Name:PHILLIPS, KIMBERLY MYERS
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MYERS
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 S GRANADOS AVE
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2008
Mailing Address - Country:US
Mailing Address - Phone:858-792-0771
Mailing Address - Fax:
Practice Address - Street 1:145 S GRANADOS AVE
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2008
Practice Address - Country:US
Practice Address - Phone:858-792-0771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20621225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist