Provider Demographics
NPI:1376187047
Name:PALMER-NICKS, KIMBERLIN RUTH (LMT)
Entity Type:Individual
Prefix:
First Name:KIMBERLIN
Middle Name:RUTH
Last Name:PALMER-NICKS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KIMBERLIN
Other - Middle Name:RUTH
Other - Last Name:NICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:3303 SW BOND AVE FL CHH12
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-418-9656
Mailing Address - Fax:
Practice Address - Street 1:3303 SW BOND AVE FL CHH12
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-418-9656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT-25235225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist