Provider Demographics
NPI:1770559940
Name:BRIGUCCIA, KIMBERLY LYNN (PT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:BRIGUCCIA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:LYNN
Other - Last Name:BEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:715 W MAIN STREET
Mailing Address - Street 2:SUITE F
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037
Mailing Address - Country:US
Mailing Address - Phone:918-298-2381
Mailing Address - Fax:918-298-2357
Practice Address - Street 1:715 W MAIN STREET
Practice Address - Street 2:SUITE F
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037
Practice Address - Country:US
Practice Address - Phone:918-298-2381
Practice Address - Fax:918-298-2357
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT3690225100000X
HIPT1490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
376585Medicare ID - Type Unspecified