Provider Demographics
NPI:1710135330
Name:EDWARDS, KIMBERLY ROSE (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ROSE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 DAISY DR
Mailing Address - Street 2:STE F-2
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-7410
Mailing Address - Country:US
Mailing Address - Phone:918-458-9235
Mailing Address - Fax:918-458-9236
Practice Address - Street 1:2234 W HOUSTON ST STE B
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3519
Practice Address - Country:US
Practice Address - Phone:918-259-1888
Practice Address - Fax:918-251-3725
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicaid
OKPENDINGMedicare PIN