Provider Demographics
NPI:1639213325
Name:KICKLIGHTER, ANDREA DAWN (PT)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:DAWN
Last Name:KICKLIGHTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:120 COUNTRY CLUB LN
Mailing Address - Street 2:
Mailing Address - City:MULBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:33860-7629
Mailing Address - Country:US
Mailing Address - Phone:863-665-8881
Mailing Address - Fax:863-665-8851
Practice Address - Street 1:3127 US HIGHWAY 98 N
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2103
Practice Address - Country:US
Practice Address - Phone:863-665-8881
Practice Address - Fax:863-665-8851
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT00006300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist