Provider Demographics
NPI:1407181191
Name:CARROLL, KIMBERLY M (PT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:M
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:M
Other - Last Name:HICKOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT, ATC
Mailing Address - Street 1:2657 AMELIA RD
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-9112
Mailing Address - Country:US
Mailing Address - Phone:904-583-2936
Mailing Address - Fax:
Practice Address - Street 1:120 N 2ND ST STE A
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4192
Practice Address - Country:US
Practice Address - Phone:904-761-8397
Practice Address - Fax:949-404-6217
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL29782255A2300X
FLPT26306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer