Provider Demographics
NPI:1528280104
Name:PATTERSON, KIMBERLY NICOLE (OTRL)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11805 ALLFORTH LN APT 2120
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4083
Mailing Address - Country:US
Mailing Address - Phone:540-588-9629
Mailing Address - Fax:
Practice Address - Street 1:427 N WENDOVER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1064
Practice Address - Country:US
Practice Address - Phone:704-304-0620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11537225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1528280104Medicaid