Provider Demographics
NPI:1700125291
Name:VANCE, KIMBERLY SUE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:VANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 TOUCHTON RD APT 927
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-8218
Mailing Address - Country:US
Mailing Address - Phone:904-437-8030
Mailing Address - Fax:
Practice Address - Street 1:9800 TOUCHTON RD APT 927
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-8218
Practice Address - Country:US
Practice Address - Phone:904-437-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22978225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant