Provider Demographics
NPI:1669577904
Name:KICERA, KIMBERLY MAY (PT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MAY
Last Name:KICERA
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 1:634 NOTTINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-4845
Mailing Address - Country:US
Mailing Address - Phone:608-877-7844
Mailing Address - Fax:
Practice Address - Street 1:1323 CRESTON PARK DR
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-1126
Practice Address - Country:US
Practice Address - Phone:608-756-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6345-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist