Healthcare Provider Details

I. General information

NPI: 1184380420
Provider Name (Legal Business Name): KIMBERLY DYKES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2021
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 EPPS BRIDGE RD
ATHENS GA
30606-3312
US

IV. Provider business mailing address

1221 CLUBHOUSE LN
STATHAM GA
30666-2617
US

V. Phone/Fax

Practice location:
  • Phone: 706-549-5382
  • Fax:
Mailing address:
  • Phone: 706-338-2433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT007963
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: