Provider Demographics
NPI:1447713235
Name:WILLEY, KIMBERLY (PTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WILLEY
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 1:9545 GRAYS SONG DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7772
Mailing Address - Country:US
Mailing Address - Phone:901-497-4550
Mailing Address - Fax:
Practice Address - Street 1:36 BAZEBERRY RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7754
Practice Address - Country:US
Practice Address - Phone:901-758-0036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant