Provider Demographics
NPI:1306113949
Name:KINNETT, KIMBERLY M/
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:M/
Last Name:KINNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-3166
Mailing Address - Country:US
Mailing Address - Phone:626-570-1606
Mailing Address - Fax:
Practice Address - Street 1:100 S RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-3166
Practice Address - Country:US
Practice Address - Phone:626-570-1606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38427Medicaid
CA38427Medicare PIN