Provider Demographics
NPI:1063786085
Name:STEWART, KIMBERLY JOAN (LMT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOAN
Last Name:STEWART
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 SW HAAS AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5611
Mailing Address - Country:US
Mailing Address - Phone:561-662-9437
Mailing Address - Fax:
Practice Address - Street 1:972 SW HAAS AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-5611
Practice Address - Country:US
Practice Address - Phone:561-662-9437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA19051172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker