Provider Demographics
NPI:1942878178
Name:KIMBERLIN, TYLER WAYNE (LMT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:WAYNE
Last Name:KIMBERLIN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 OASIS GRAND BLVD APT 2106
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-1607
Mailing Address - Country:US
Mailing Address - Phone:239-631-9622
Mailing Address - Fax:
Practice Address - Street 1:3040 OASIS GRAND BLVD APT 2106
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-1607
Practice Address - Country:US
Practice Address - Phone:239-631-9622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA75941225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist