Provider Demographics
NPI:1700848603
Name:WILLBURN, KENT (PT)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:WILLBURN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:KENT
Other - Middle Name:
Other - Last Name:WILLBURN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3004 W FAIDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4109
Mailing Address - Country:US
Mailing Address - Phone:308-382-0344
Mailing Address - Fax:
Practice Address - Street 1:3004 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4109
Practice Address - Country:US
Practice Address - Phone:308-382-0344
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist