Healthcare Provider Details

I. General information

NPI: 1295123461
Provider Name (Legal Business Name): KIM KUYKENDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13512 LITTLE BROOK DR
CLIFTON VA
20124-1083
US

IV. Provider business mailing address

13512 LITTLE BROOK DR
CLIFTON VA
20124-1083
US

V. Phone/Fax

Practice location:
  • Phone: 703-830-0313
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306604012
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: