Basic Information
Provider Information | |||||||||
NPI: | 1477863157 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MELVAN | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | FAITH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HARRIS | ||||||||
OtherFirstName: | KIMBERLY | ||||||||
OtherMiddleName: | FAITH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 102831 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303682831 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047786330 | ||||||||
FaxNumber: | 4047786370 | ||||||||
Practice Location | |||||||||
Address1: | 59 EXECUTIVE PARK S | ||||||||
Address2: | SUITE 1100 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303292208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047786330 | ||||||||
FaxNumber: | 4047786370 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/15/2010 | ||||||||
LastUpdateDate: | 11/03/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 07968R | LA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.