Provider Demographics
NPI:1962853689
Name:GOODWIN, KIMBERLY DAWN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DAWN
Other - Last Name:VANZANTEN/ZIMMERMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:431 NE TAHUYA RIVER DRIVE
Mailing Address - Street 2:
Mailing Address - City:TAHUYA
Mailing Address - State:WA
Mailing Address - Zip Code:98588
Mailing Address - Country:US
Mailing Address - Phone:360-258-2405
Mailing Address - Fax:
Practice Address - Street 1:431 NE TAHUYA RIVER DRIVE
Practice Address - Street 2:
Practice Address - City:TAHUYA
Practice Address - State:WA
Practice Address - Zip Code:98588
Practice Address - Country:US
Practice Address - Phone:360-258-2405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK104471225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist