Provider Demographics
NPI:1790139772
Name:FELLENBAUM, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FELLENBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6024 PARKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:EAST PETERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17520-1245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 S HOME AVE
Practice Address - Street 2:
Practice Address - City:TOPTON
Practice Address - State:PA
Practice Address - Zip Code:19562-1317
Practice Address - Country:US
Practice Address - Phone:610-682-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6241225200000X
PATE010881225200000X
PATEI004832225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant