Provider Demographics
NPI:1437206117
Name:WELLS, KIMBERLY (ITDS)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7626 ALTUS DR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-0949
Mailing Address - Country:US
Mailing Address - Phone:904-610-8379
Mailing Address - Fax:
Practice Address - Street 1:3311 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3704
Practice Address - Country:US
Practice Address - Phone:904-396-1462
Practice Address - Fax:904-396-1199
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist