Provider Demographics
NPI:1134198211
Name:SMITH, KIMBERLY ANN (MS ED, ATC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS ED, ATC
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:SINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:165 HARVEST GLENN DR
Mailing Address - Street 2:
Mailing Address - City:DAVIS JUNCTION
Mailing Address - State:IL
Mailing Address - Zip Code:61020-9797
Mailing Address - Country:US
Mailing Address - Phone:815-645-2439
Mailing Address - Fax:
Practice Address - Street 1:5510 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2381
Practice Address - Country:US
Practice Address - Phone:815-395-4505
Practice Address - Fax:815-395-4507
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer