Provider Demographics
NPI:1467775098
Name:BUSH, KIMBERLY KAY (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:BUSH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:KAY
Other - Last Name:AHRENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:650 N SHORELINE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6677
Mailing Address - Country:US
Mailing Address - Phone:907-376-6363
Mailing Address - Fax:907-376-6366
Practice Address - Street 1:650 N SHORELINE DR STE 101
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6677
Practice Address - Country:US
Practice Address - Phone:907-376-6363
Practice Address - Fax:907-376-6366
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK678225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant