Provider Demographics
NPI:1982135497
Name:VANDIVER, KIMBERLY (OTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:VANDIVER
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4087 W FOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-7686
Mailing Address - Country:US
Mailing Address - Phone:417-389-9165
Mailing Address - Fax:
Practice Address - Street 1:4087 W FOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-7686
Practice Address - Country:US
Practice Address - Phone:417-389-9165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-26
Last Update Date:2017-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01310224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant