Provider Demographics
NPI:1174603054
Name:ELLIS, KIMBERLY S (PT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:ELLIS
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 1:10613 NE 174TH PL
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3777
Mailing Address - Country:US
Mailing Address - Phone:206-920-8998
Mailing Address - Fax:425-485-7022
Practice Address - Street 1:10613 NE 174TH PL
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3777
Practice Address - Country:US
Practice Address - Phone:206-920-8998
Practice Address - Fax:425-485-7022
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007913225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPIN# 8863935Medicare ID - Type UnspecifiedMEDICARE PROVIDER #