Provider Demographics
NPI:1558108175
Name:ITO, KIMBERLY AKIYE MICHIKO (DPT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:AKIYE MICHIKO
Last Name:ITO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SOUTHVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-0359
Mailing Address - Country:US
Mailing Address - Phone:330-554-8041
Mailing Address - Fax:
Practice Address - Street 1:150 FRANCAM DR # 124
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-4500
Practice Address - Country:US
Practice Address - Phone:910-229-3924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP-CP032402T225100000X
OHPT021240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist