Provider Demographics
NPI:1699885368
Name:OHARA, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:OHARA
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 1:90 MARK ST
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-3566
Mailing Address - Country:US
Mailing Address - Phone:850-654-1313
Mailing Address - Fax:
Practice Address - Street 1:1008 AIRPORT RD
Practice Address - Street 2:SUITE A
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2823
Practice Address - Country:US
Practice Address - Phone:850-837-3349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA 18367OtherLICENSE #