Provider Demographics
NPI:1710319199
Name:PARKS, KIMBERLY RUTH SPENCER (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:RUTH SPENCER
Last Name:PARKS
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 1:8725 DIGITAL DR
Mailing Address - Street 2:APT 302
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4384
Mailing Address - Country:US
Mailing Address - Phone:813-404-7454
Mailing Address - Fax:
Practice Address - Street 1:8725 DIGITAL DR
Practice Address - Street 2:APT 302
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4384
Practice Address - Country:US
Practice Address - Phone:813-404-7454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5141225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant