Provider Demographics
NPI:1578769113
Name:PETERSON, KIMBERLY ANN (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:WECKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 W 64TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1001
Mailing Address - Country:US
Mailing Address - Phone:952-767-6788
Mailing Address - Fax:952-285-2830
Practice Address - Street 1:2400 W 64TH ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1001
Practice Address - Country:US
Practice Address - Phone:952-767-6788
Practice Address - Fax:952-285-2830
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7687225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist