Provider Demographics
NPI:1487945770
Name:MARLEY, KIM C
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:C
Last Name:MARLEY
Suffix:
Gender:F
Credentials:
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 317
Mailing Address - Street 2:
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-0317
Mailing Address - Country:US
Mailing Address - Phone:208-263-7577
Mailing Address - Fax:
Practice Address - Street 1:476978 HWY 95
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-6978
Practice Address - Country:US
Practice Address - Phone:208-263-7577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-240225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant