=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093919110
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY DAVIS P.T.A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2007
-----------------------------------------------------
Last Update Date | 11/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 E RANDOL MILL RD STE 100
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76011-5841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-461-0154
-----------------------------------------------------
Fax | 817-275-9792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19307 E 105TH ST S
-----------------------------------------------------
City | BROKEN ARROW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74014-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 2051150
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 1975
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------