Provider Demographics
NPI:1669582375
Name:MAUK, KIMBERLY MARIE (PTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:MAUK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5427 PEACH DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32571-2773
Mailing Address - Country:US
Mailing Address - Phone:301-908-1356
Mailing Address - Fax:
Practice Address - Street 1:3876 HIGHWAY 90
Practice Address - Street 2:ANDREWS INSTITUTE REHABILITATION
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571
Practice Address - Country:US
Practice Address - Phone:448-227-7075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
FL32737225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA1619OtherLICENSE#