Provider Demographics
NPI:1568505352
Name:CANADA, KIMBERLY (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CANADA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 239
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-0239
Mailing Address - Country:US
Mailing Address - Phone:606-549-1183
Mailing Address - Fax:606-549-8107
Practice Address - Street 1:118 S 3RD ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1214
Practice Address - Country:US
Practice Address - Phone:606-549-1183
Practice Address - Fax:606-549-8107
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA00459225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant