Provider Demographics
NPI:1194473868
Name:LAFAVE, KIMBERLY JOY (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOY
Last Name:LAFAVE
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JOY
Other - Last Name:STREFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1415 PORTLAND AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3039
Mailing Address - Country:US
Mailing Address - Phone:585-922-4416
Mailing Address - Fax:
Practice Address - Street 1:1415 PORTLAND AVE MOB
Practice Address - Street 2:SUITE 245
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3039
Practice Address - Country:US
Practice Address - Phone:585-922-4496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-12
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029390363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical