=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063283331
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIM EDWARDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2024
-----------------------------------------------------
Last Update Date | 01/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10133 SHERRILL BLVD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37932-3347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-392-2811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11040 W LANE AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85307-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-695-4537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 008854
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------