Provider Demographics
NPI:1861594566
Name:HANNON, KIMBERLY (PT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HANNON
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 1:760B BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-2598
Mailing Address - Country:US
Mailing Address - Phone:850-892-7772
Mailing Address - Fax:888-308-1539
Practice Address - Street 1:24555 US HIGHWAY 331 S UNIT J202
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-6183
Practice Address - Country:US
Practice Address - Phone:770-569-7287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT38922225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA602028050AMedicaid