Provider Demographics
NPI:1396382123
Name:PHILLIPS, KIMYA LASHONDA (PTA)
Entity Type:Individual
Prefix:MS
First Name:KIMYA
Middle Name:LASHONDA
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16462 PINE WOOD ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1466
Mailing Address - Country:US
Mailing Address - Phone:951-833-1132
Mailing Address - Fax:
Practice Address - Street 1:16462 PINE WOOD ST
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1466
Practice Address - Country:US
Practice Address - Phone:909-833-1132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA6430225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant