Provider Demographics
NPI:1689652349
Name:SANDERS, KIMBERLY M (PT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:M
Last Name:SANDERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 NE HORRY AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-2125
Mailing Address - Country:US
Mailing Address - Phone:850-973-3626
Mailing Address - Fax:850-973-6536
Practice Address - Street 1:456 W BASE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-2061
Practice Address - Country:US
Practice Address - Phone:850-973-2187
Practice Address - Fax:850-973-6536
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2681225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7137ZMedicare ID - Type Unspecified