MEDICARE: ANTIONETTE KIMBREW 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	17-0962	NV

General Provider Information

NPI Number	:	1508362302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTIONETTE KIMBREW OTR/L

Provider Business Mailing Address
First Line	:	2662 N. BUFFALO DRIVE
Second Line	:	UNIT 1407
City	:	LAS VEGAS
State	:	NV
Zip	:	89128
Country	:	US
Telephone Number	:	773-675-0815
Fax Number	:

Provider Business Practice Location Address
First Line	:	2662 N. BUFFALO DRIVE
Second Line	:	UNIT 1407
City	:	LAS VEGAS
State	:	NV
Zip	:	89128
Country	:	US
Telephone Number	:	773-675-0815
Fax Number	:

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

Provider Enumeration Date	:	04/02/2018
Last Update Date	:	04/02/2018

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