Provider Demographics
NPI:1598262396
Name:KILLINGSWORTH, SUZANNE NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:NICOLE
Last Name:KILLINGSWORTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:NICOLE
Other - Last Name:RODGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3001 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-1196
Mailing Address - Country:US
Mailing Address - Phone:816-380-6525
Mailing Address - Fax:816-380-4963
Practice Address - Street 1:3001 E ELM ST
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-1196
Practice Address - Country:US
Practice Address - Phone:816-380-6525
Practice Address - Fax:816-380-4963
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010023566225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist