Provider Demographics
NPI:1275017303
Name:GAGNON, KIMBERLY (LMT, MMP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GAGNON
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:GAGNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:KIMBERLY GAGNON, MMP
Mailing Address - Street 1:575 S WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5713
Mailing Address - Country:US
Mailing Address - Phone:603-921-0087
Mailing Address - Fax:
Practice Address - Street 1:575 S WILLOW ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-5713
Practice Address - Country:US
Practice Address - Phone:603-232-3233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3485M208100000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation