Provider Demographics
NPI:1336401520
Name:MONTELONE, KIMBERLY (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MONTELONE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2537 ROUTE 9
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-2442
Mailing Address - Country:US
Mailing Address - Phone:518-289-2400
Mailing Address - Fax:518-289-2410
Practice Address - Street 1:2537 ROUTE 9
Practice Address - Street 2:SUITE 203
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-2442
Practice Address - Country:US
Practice Address - Phone:518-289-2400
Practice Address - Fax:518-289-2410
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF337315363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400415191OtherMEDICARE
NY03465309Medicaid