Provider Demographics
NPI:1124102785
Name:BRISCO, KIMBERLY ANN (PT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:BRISCO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 AIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3652
Mailing Address - Country:US
Mailing Address - Phone:928-757-1211
Mailing Address - Fax:928-757-8826
Practice Address - Street 1:2120 AIRWAY AVENUE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3027
Practice Address - Country:US
Practice Address - Phone:928-757-1211
Practice Address - Fax:928-757-8826
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5866225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ850158Medicaid
AZ036550Medicare Oscar/Certification