Provider Demographics
NPI:1861563967
Name:IZZO, KIMBERLY A (PT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:IZZO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2848
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-0015
Mailing Address - Country:US
Mailing Address - Phone:404-509-7986
Mailing Address - Fax:770-517-8107
Practice Address - Street 1:806 RIDGE CREEK LN
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6207
Practice Address - Country:US
Practice Address - Phone:404-509-7986
Practice Address - Fax:770-517-8107
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2014-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0056902251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000859064FMedicaid