Provider Demographics
NPI:1841599164
Name:CHANDRA, KIMBERLY (PTA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:CHANDRA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14210 29TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-5012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25117 SW PARKWAY AVE STE D
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9697
Practice Address - Country:US
Practice Address - Phone:888-757-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60153870225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant