Basic Information
| Provider Information | |||||||||
| NPI: | 1639554777 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KINGSBURY | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10880 W M 28 | ||||||||
| Address2: | PO BOX 477 | ||||||||
| City: | BRIMLEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497159212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067481128 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2120 43RD ST SE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495083772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162811144 | ||||||||
| FaxNumber: | 6162811221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2015 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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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 | 5501005144 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.