Provider Demographics
NPI:1245406206
Name:NELSON, KIMBERLY (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:NELSON
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 1:896 RIDING LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-4716
Mailing Address - Country:US
Mailing Address - Phone:630-849-5336
Mailing Address - Fax:
Practice Address - Street 1:200 HOWARD AVE
Practice Address - Street 2:STE 248
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-5906
Practice Address - Country:US
Practice Address - Phone:847-803-0774
Practice Address - Fax:847-803-0821
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-003549225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist