Provider Demographics
NPI:1477882991
Name:SAN NICOLAS, KATHRYN D (DPT)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:D
Last Name:SAN NICOLAS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 RIM DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-9023
Mailing Address - Country:US
Mailing Address - Phone:254-368-9691
Mailing Address - Fax:
Practice Address - Street 1:5301 BRYANT IRVIN RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4030
Practice Address - Country:US
Practice Address - Phone:817-294-2280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1193243225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist