Provider Demographics
NPI:1326644428
Name:NICHOLS, KIMBERLY ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:132 BLAIR WAY
Mailing Address - Street 2:
Mailing Address - City:GUYTON
Mailing Address - State:GA
Mailing Address - Zip Code:31312-5316
Mailing Address - Country:US
Mailing Address - Phone:912-531-6887
Mailing Address - Fax:
Practice Address - Street 1:11702 MERCY BLVD # B-2C
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1750
Practice Address - Country:US
Practice Address - Phone:912-819-2446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002573225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant