Provider Demographics
NPI:1689108391
Name:MCCARTNEY, KIMBERLY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MCCARTNEY
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 HAWTHORNE PL
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-5652
Mailing Address - Country:US
Mailing Address - Phone:210-383-5091
Mailing Address - Fax:
Practice Address - Street 1:1311 FLORIDA AVE BLDG 36087
Practice Address - Street 2:
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403-5207
Practice Address - Country:US
Practice Address - Phone:210-383-5091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT63902255A2300X
FLAL58382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer