Provider Demographics
NPI:1235201450
Name:CONKLIN, KIM MARIE (RPT)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MARIE
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:RPT
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 1502
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34656-1502
Mailing Address - Country:US
Mailing Address - Phone:727-848-6747
Mailing Address - Fax:727-847-3107
Practice Address - Street 1:6926 HILLS DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-2710
Practice Address - Country:US
Practice Address - Phone:727-848-6747
Practice Address - Fax:727-847-3107
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 178092251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884978100Medicaid
FLY0408OtherBLUE CROSS & BLUE SHIELD