Healthcare Provider Details

I. General information

NPI: 1619486685
Provider Name (Legal Business Name): KIMBERLY LYNN WANG PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38250 A AVE
ZEPHYRHILLS FL
33542-5759
US

IV. Provider business mailing address

5707 HAWKPARK BLVD
LITHIA FL
33547-5821
US

V. Phone/Fax

Practice location:
  • Phone: 813-782-5508
  • Fax:
Mailing address:
  • Phone: 801-602-4087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA24342
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: