Provider Demographics
NPI:1659850113
Name:SMITH, KAITLYN J (DPT)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:J
Other - Last Name:TIMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2105 E ENTERPRISE AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-560-1083
Mailing Address - Fax:920-560-1098
Practice Address - Street 1:402 EUREKA ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971
Practice Address - Country:US
Practice Address - Phone:920-896-0430
Practice Address - Fax:920-896-0491
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39-1930290OtherGROUP TAX ID
WI1407857790OtherGROUP NPI