Provider Demographics
NPI:1982737086
Name:ARCHER, KIMI JENSEN (MSPT)
Entity type:Individual
Prefix:MRS
First Name:KIMI
Middle Name:JENSEN
Last Name:ARCHER
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:MISS
Other - First Name:KIMI
Other - Middle Name:ROXANNE
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8205 COUNTY ROUTE 70
Mailing Address - Street 2:
Mailing Address - City:AVOCA
Mailing Address - State:NY
Mailing Address - Zip Code:14809-9549
Mailing Address - Country:US
Mailing Address - Phone:607-566-2019
Mailing Address - Fax:
Practice Address - Street 1:7571 STATE ROUTE 54
Practice Address - Street 2:IRA DAVENPORT MEM. HOSPITAL, REHAB SERVICES DEPARTMENT
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-9504
Practice Address - Country:US
Practice Address - Phone:607-776-8543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009329-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist