Provider Demographics
NPI:1720386691
Name:KNUDSEN, KIMBERLY WHEELER (OT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:WHEELER
Last Name:KNUDSEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 ABBIE LN
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-5983
Mailing Address - Country:US
Mailing Address - Phone:850-505-9989
Mailing Address - Fax:850-505-9990
Practice Address - Street 1:2310 ABBIE LN
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5983
Practice Address - Country:US
Practice Address - Phone:850-505-9989
Practice Address - Fax:850-505-9990
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10609172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFL OT10609OtherFL STATE LICENSE