Provider Demographics
NPI:1720324619
Name:GANIERE, KIMBERLY ELIZABETH (LMT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ELIZABETH
Last Name:GANIERE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32952 SW KEYS CREST DR
Mailing Address - Street 2:
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-2629
Mailing Address - Country:US
Mailing Address - Phone:503-543-8865
Mailing Address - Fax:
Practice Address - Street 1:32952 SW KEYS CREST DR
Practice Address - Street 2:
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-2629
Practice Address - Country:US
Practice Address - Phone:503-543-8865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7975172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist