Provider Demographics
NPI:1730110982
Name:MAZZELLA, KIMBERLY J (PT)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:J
Last Name:MAZZELLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 S VANGUARD WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8541
Mailing Address - Country:US
Mailing Address - Phone:208-960-0930
Mailing Address - Fax:208-960-0935
Practice Address - Street 1:875 S VANGUARD WAY STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8541
Practice Address - Country:US
Practice Address - Phone:208-960-0932
Practice Address - Fax:208-960-0935
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-7231225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist