Provider Demographics
NPI:1285109462
Name:STRONG, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:STRONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 FROST MEADOW TRL
Mailing Address - Street 2:
Mailing Address - City:GREECE
Mailing Address - State:NY
Mailing Address - Zip Code:14612-2358
Mailing Address - Country:US
Mailing Address - Phone:585-286-6584
Mailing Address - Fax:
Practice Address - Street 1:19 FROST MEADOW TRL
Practice Address - Street 2:
Practice Address - City:GREECE
Practice Address - State:NY
Practice Address - Zip Code:14612-2358
Practice Address - Country:US
Practice Address - Phone:585-286-6584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331158164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid