Provider Demographics
NPI:1508362302
Name:KIMBREW, ANTIONETTE (OTR/L)
Entity Type:Individual
Prefix:
First Name:ANTIONETTE
Middle Name:
Last Name:KIMBREW
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2662 N. BUFFALO DRIVE
Mailing Address - Street 2:UNIT 1407
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128
Mailing Address - Country:US
Mailing Address - Phone:773-675-0815
Mailing Address - Fax:
Practice Address - Street 1:2662 N. BUFFALO DRIVE
Practice Address - Street 2:UNIT 1407
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128
Practice Address - Country:US
Practice Address - Phone:773-675-0815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17-0962225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist