Provider Demographics
NPI:1427137835
Name:SMITH, KIMBERLY ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 TIMBER TRL
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-2377
Mailing Address - Country:US
Mailing Address - Phone:615-473-8161
Mailing Address - Fax:
Practice Address - Street 1:120 N TOWER RD
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1929
Practice Address - Country:US
Practice Address - Phone:618-549-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-04
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3732225200000X
IL160.004882225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant