Provider Demographics
NPI:1992082481
Name:LUPER, KIMBERLY DAWN (LMT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:LUPER
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 1:784 CHENA HILLS DR APT A
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-5710
Mailing Address - Country:US
Mailing Address - Phone:907-978-4418
Mailing Address - Fax:
Practice Address - Street 1:3039 DAVIS RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5234
Practice Address - Country:US
Practice Address - Phone:907-452-3600
Practice Address - Fax:907-452-3695
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5684172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist