Provider Demographics
NPI:1710531306
Name:WILSON, KIMBERLYN JENA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLYN
Middle Name:JENA
Last Name:WILSON
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 1:162 SHOAL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROUND OAK
Mailing Address - State:GA
Mailing Address - Zip Code:31038-3001
Mailing Address - Country:US
Mailing Address - Phone:478-550-3702
Mailing Address - Fax:
Practice Address - Street 1:260 W CLINTON ST STE 2
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:GA
Practice Address - Zip Code:31032-5464
Practice Address - Country:US
Practice Address - Phone:478-936-7621
Practice Address - Fax:888-369-9044
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist