Provider Demographics
NPI:1124290523
Name:PRUCHA, KIMBERLY M (MPT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:PRUCHA
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 MOUNT ROSE ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-3224
Mailing Address - Country:US
Mailing Address - Phone:850-797-0636
Mailing Address - Fax:
Practice Address - Street 1:837 MOUNT ROSE ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-3224
Practice Address - Country:US
Practice Address - Phone:850-797-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBN938ZOtherMEDICARE PTAN