Provider Demographics
NPI:1760733356
Name:SHACKELFORD, KIMBERLY LARUE KWAN (DPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LARUE KWAN
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LARUE KWAN
Other - Last Name:ASATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3171 RANCHO SILVA DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-1132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 MARCONI AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-5309
Practice Address - Country:US
Practice Address - Phone:916-481-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1221081225100000X
CA40045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist