Provider Demographics
NPI:1184264293
Name:KLAYSON, KIMBERLY JO (PTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:KLAYSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JO
Other - Last Name:STEVENS
Other - Suffix:II
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:201 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1775
Practice Address - Country:US
Practice Address - Phone:701-239-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND0903A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant