Provider Demographics
NPI:1144331000
Name:HANSEN, KIMBERLY STACIE (ATC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:STACIE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 S MONTEGO APT F
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-0438
Mailing Address - Country:US
Mailing Address - Phone:909-947-3731
Mailing Address - Fax:
Practice Address - Street 1:13400 PIPELINE AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4959
Practice Address - Country:US
Practice Address - Phone:909-591-3902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer