Provider Demographics
NPI:1841795465
Name:LONG, KIMBERLY M
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:LONG
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 1:1427 HOLLY RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801
Mailing Address - Country:US
Mailing Address - Phone:863-430-3177
Mailing Address - Fax:
Practice Address - Street 1:38250 A AVE
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS, FL
Practice Address - State:FL
Practice Address - Zip Code:33542
Practice Address - Country:US
Practice Address - Phone:813-782-5508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27309225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL520513905490OtherDR LICENSE