Provider Demographics
NPI:1457543449
Name:MARIETTA, KIMBERLEY ANN (MOTR/L)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLEY
Middle Name:ANN
Last Name:MARIETTA
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 EASTON TER
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-3219
Mailing Address - Country:US
Mailing Address - Phone:863-680-1337
Mailing Address - Fax:
Practice Address - Street 1:16 LAKE HUNTER DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-1297
Practice Address - Country:US
Practice Address - Phone:863-513-7588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT8405225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist