Provider Demographics
NPI:1962837203
Name:PRIESKORN, KIMBERLY ROSE (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROSE
Last Name:PRIESKORN
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 1:538 W KEITH RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48657-9317
Mailing Address - Country:US
Mailing Address - Phone:231-740-8089
Mailing Address - Fax:
Practice Address - Street 1:1149 W MONROE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MI
Practice Address - Zip Code:48880-9736
Practice Address - Country:US
Practice Address - Phone:989-681-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002127225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant