Provider Demographics
NPI:1336671817
Name:CLEMONS, KIMBERLY M (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:CLEMONS
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 1:4027 BOYD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4548
Mailing Address - Country:US
Mailing Address - Phone:817-298-1681
Mailing Address - Fax:
Practice Address - Street 1:1111 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-3425
Practice Address - Country:US
Practice Address - Phone:817-877-1199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1110369208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation