Basic Information
| Provider Information | |||||||||
| NPI: | 1104369164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACVANE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | WALLINGFORD | ||||||||
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| OtherLastName: | WALLINGFORD | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | D | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 73 NEWTON RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | PLAISTOW | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038652424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783887272 | ||||||||
| FaxNumber: | 9783887373 | ||||||||
| Practice Location | |||||||||
| Address1: | 331 VERANDA ST | ||||||||
| Address2: | BUILDING 6, RM 3311 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041035545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075360702 | ||||||||
| FaxNumber: | 2075360785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2016 | ||||||||
| LastUpdateDate: | 01/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT4737 | ME | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.