Provider Demographics
NPI:1518932912
Name:NICHOLS, KIMBERLY SUE (PT, ATC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1306
Mailing Address - Country:US
Mailing Address - Phone:585-637-0790
Mailing Address - Fax:585-637-3572
Practice Address - Street 1:880 ELMGROVE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-1320
Practice Address - Country:US
Practice Address - Phone:585-247-8535
Practice Address - Fax:585-247-1957
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000884225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7695330OtherAETNA
NY110575FTOtherPREFERRED CARE
NYCC8626Medicare ID - Type Unspecified