Provider Demographics
NPI:1124502398
Name:MCCORMICK, KIMBERLY DOMINIQUE (RN)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DOMINIQUE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:DOMINIQUE
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:29
Mailing Address - Street 2:MACINTOSH DRIVE
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941
Mailing Address - Country:US
Mailing Address - Phone:347-678-3402
Mailing Address - Fax:
Practice Address - Street 1:29
Practice Address - Street 2:MACINTOSH DRIVE
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941
Practice Address - Country:US
Practice Address - Phone:347-678-3402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3327211164W00000X
NY890852163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty