Provider Demographics
NPI:1710210620
Name:RYAN, KIMBERLY (OTR)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12700 VISTA PINE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-7973
Mailing Address - Country:US
Mailing Address - Phone:239-209-7927
Mailing Address - Fax:
Practice Address - Street 1:12700 VISTA PINE CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-7973
Practice Address - Country:US
Practice Address - Phone:239-209-7927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3614225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist