=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154638542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY A GOODNITE LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2010
-----------------------------------------------------
Last Update Date | 09/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 427 MAIN ST
-----------------------------------------------------
City | PECATONICA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61063-7737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-239-1121
-----------------------------------------------------
Fax | 815-239-2766
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 699
-----------------------------------------------------
City | PECATONICA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61063-0699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-239-1121
-----------------------------------------------------
Fax | 815-239-2766
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 227011185
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------