Provider Demographics
NPI:1396105813
Name:DIAMOND, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:DIAMOND
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 1:12787 COUNTY HIGHWAY H
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54768-5814
Mailing Address - Country:US
Mailing Address - Phone:715-703-0942
Mailing Address - Fax:
Practice Address - Street 1:W4266 COUNTY ROAD X
Practice Address - Street 2:
Practice Address - City:OWEN
Practice Address - State:WI
Practice Address - Zip Code:54460-3301
Practice Address - Country:US
Practice Address - Phone:715-229-2172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2351225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant