Provider Demographics
NPI:1396787750
Name:TRUJILLO, KIMBERLY SHIRL (PT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SHIRL
Last Name:TRUJILLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4534 RAEFORD RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3230
Mailing Address - Country:US
Mailing Address - Phone:910-425-5999
Mailing Address - Fax:910-425-6376
Practice Address - Street 1:3013C RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5441
Practice Address - Country:US
Practice Address - Phone:910-484-9663
Practice Address - Fax:910-484-6668
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9548225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9548OtherLICENSE NO
NC079CFOtherBCBS PROVIDER ID
NC7301894Medicaid
NC079CFOtherBCBS PROVIDER ID