Basic Information
Provider Information
NPI: 1003146192
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MANN
FirstName: KIMBERLY
MiddleName: B
NamePrefix:  
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 530 W GANNON AVE
Address2:  
City: ZEBULON
State: NC
PostalCode: 275972510
CountryCode: US
TelephoneNumber: 9192690107
FaxNumber: 9192690207
Practice Location
Address1: 530 W GANNON AVE
Address2:  
City: ZEBULON
State: NC
PostalCode: 275972510
CountryCode: US
TelephoneNumber: 9192690107
FaxNumber: 9192690207
Other Information
ProviderEnumerationDate: 01/12/2010
LastUpdateDate: 01/12/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X2413NCY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

ID Information
IDTypeStateIssuerDescription
PENDING05NC MEDICAID


Home