Provider Demographics
NPI:1902013634
Name:KIMBALL, NAOMI KNAAK (PT)
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:KNAAK
Last Name:KIMBALL
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 1:2425 CLEVELAND AVE
Mailing Address - Street 2:SUITE 135
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2990
Mailing Address - Country:US
Mailing Address - Phone:707-483-3244
Mailing Address - Fax:707-536-9490
Practice Address - Street 1:2425 CLEVELAND AVE
Practice Address - Street 2:SUITE 135
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2990
Practice Address - Country:US
Practice Address - Phone:707-483-3244
Practice Address - Fax:707-536-9490
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6427OtherPHYSICAL THERAPIST LICENS