Provider Demographics
NPI:1669587754
Name:NICHOLSON, KIMBERLY JOAN (PTA/LMT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JOAN
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PTA/LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 3RD ST
Mailing Address - Street 2:
Mailing Address - City:STONEWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26301-4645
Mailing Address - Country:US
Mailing Address - Phone:304-622-8867
Mailing Address - Fax:
Practice Address - Street 1:230 HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-8558
Practice Address - Country:US
Practice Address - Phone:304-269-8097
Practice Address - Fax:304-269-8187
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000951225200000X
WV2004-1442225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist