Provider Demographics
NPI:1154607356
Name:SHAFFER, KIMBERLY RAE (ATC)
Entity type:Individual
Prefix:MR
First Name:KIMBERLY
Middle Name:RAE
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PENROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81240-9775
Mailing Address - Country:US
Mailing Address - Phone:719-429-5983
Mailing Address - Fax:
Practice Address - Street 1:1350 8TH ST
Practice Address - Street 2:
Practice Address - City:PENROSE
Practice Address - State:CO
Practice Address - Zip Code:81240-9775
Practice Address - Country:US
Practice Address - Phone:719-429-5983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20000071122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer