Provider Demographics
NPI:1922766880
Name:SULLIVAN, KIMBERLY (PTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 GARDNER LN
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-3415
Mailing Address - Country:US
Mailing Address - Phone:865-803-1336
Mailing Address - Fax:
Practice Address - Street 1:914 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:DANDRIDGE
Practice Address - State:TN
Practice Address - Zip Code:37725-4700
Practice Address - Country:US
Practice Address - Phone:865-397-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4911225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant