Provider Demographics
NPI:1104903640
Name:DEMAY, KIMBERLY SUSAN (DC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUSAN
Last Name:DEMAY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:SUSAN
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:219 LAKE STREET
Mailing Address - Street 2:
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527
Mailing Address - Country:US
Mailing Address - Phone:315-536-3700
Mailing Address - Fax:315-694-9085
Practice Address - Street 1:219 LAKE STREET
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527
Practice Address - Country:US
Practice Address - Phone:315-536-3700
Practice Address - Fax:315-694-9085
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010742-1111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA0304Medicare ID - Type UnspecifiedCHIROPRACTOR
NY164536ANMedicare UPIN