Provider Demographics
NPI:1013663426
Name:WILSON, KIMBERLY NICOLE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12235 HERITAGE SPRINGS DR APT 201
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-6928
Mailing Address - Country:US
Mailing Address - Phone:650-796-9610
Mailing Address - Fax:
Practice Address - Street 1:11627 TELEGRAPH RD STE 105
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-6800
Practice Address - Country:US
Practice Address - Phone:562-948-4004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT300974225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist