Provider Demographics
NPI:1427326420
Name:FUESTING, KIMBRA (ATC)
Entity type:Individual
Prefix:
First Name:KIMBRA
Middle Name:
Last Name:FUESTING
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 1:110 HORTON FIELD HOUSE
Mailing Address - Street 2:CAMPUS BOX 7130
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61790-0001
Mailing Address - Country:US
Mailing Address - Phone:309-438-0647
Mailing Address - Fax:309-438-2131
Practice Address - Street 1:110 HORTON FIELD HOUSE
Practice Address - Street 2:CAMPUS BOX 7130
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790-0001
Practice Address - Country:US
Practice Address - Phone:309-438-0647
Practice Address - Fax:309-438-2131
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0026042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer