Provider Demographics
NPI:1689863367
Name:FLETCHER, KIMBERLY MARIE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:NEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:872 TROY RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-4046
Mailing Address - Country:US
Mailing Address - Phone:208-882-1426
Mailing Address - Fax:208-882-1428
Practice Address - Street 1:872 TROY RD
Practice Address - Street 2:SUITE 180
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4046
Practice Address - Country:US
Practice Address - Phone:208-882-1426
Practice Address - Fax:208-882-1428
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2289225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist