Healthcare Provider Details

I. General information

NPI: 1992156988
Provider Name (Legal Business Name): KIMBERLY KENYON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11710 WILSHIRE BLVD
LOS ANGELES CA
90025-1503
US

IV. Provider business mailing address

1300 S BARRINGTON AVE APT 5
LOS ANGELES CA
90025-5679
US

V. Phone/Fax

Practice location:
  • Phone: 310-494-1422
  • Fax:
Mailing address:
  • Phone: 847-970-1595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.022208
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT293586
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: