Provider Demographics
NPI:1528036159
Name:FISHER, KIMBERLY A (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:FISHER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24229 BAXTER DR
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-4754
Mailing Address - Country:US
Mailing Address - Phone:424-644-0003
Mailing Address - Fax:
Practice Address - Street 1:1950 SAWTELLE BLVD
Practice Address - Street 2:303
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7014
Practice Address - Country:US
Practice Address - Phone:310-401-6410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3718225100000X
CA34944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
24R601366Medicare PIN