Provider Demographics
NPI:1992126973
Name:SPROULE, KYMBERLEE
Entity type:Individual
Prefix:
First Name:KYMBERLEE
Middle Name:
Last Name:SPROULE
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 1:350 NE 60TH AVE
Mailing Address - Street 2:E7
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3766
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4560 SE INTERNATIONAL WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-4628
Practice Address - Country:US
Practice Address - Phone:971-206-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR244463224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant