Provider Demographics
NPI:1689843112
Name:GALLAGHER, KIMBERLY L (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 585
Mailing Address - Street 2:
Mailing Address - City:PEA RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72751-0585
Mailing Address - Country:US
Mailing Address - Phone:479-273-2345
Mailing Address - Fax:
Practice Address - Street 1:1501 SE WALTON BLVD STE 109
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3745
Practice Address - Country:US
Practice Address - Phone:479-273-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA2023225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPTA2023OtherPTA LICENSE