MEDICARE: MRS. KIMBRA SUZANNE EDGE OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OT002070	GA

General Provider Information

NPI Number	:	1508124942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBRA SUZANNE EDGE OTR/L

Provider Business Mailing Address
First Line	:	45 DOVER CLIFF WAY
Second Line	:
City	:	JOHNS CREEK
State	:	GA
Zip	:	30022-3202
Country	:	US
Telephone Number	:	678-849-5847
Fax Number	:

Provider Business Practice Location Address
First Line	:	11190 MEDLOCK BRIDGE RD
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30097-2578
Country	:	US
Telephone Number	:	678-849-5847
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2012
Last Update Date	:	02/07/2020

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Directions to “ MRS. KIMBRA SUZANNE EDGE OTR/L” Practice Location

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