Healthcare Provider Details

I. General information

NPI: 1952829558
Provider Name (Legal Business Name): KIMBERLY POWELL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2017
Last Update Date: 09/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E OAK STREET
APOPKA FL
32703
US

IV. Provider business mailing address

3442 MALLAIG COURT
APOPKA FL
32712
US

V. Phone/Fax

Practice location:
  • Phone: 321-256-3051
  • Fax:
Mailing address:
  • Phone: 407-339-7767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA14232
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: