Provider Demographics
NPI:1467274548
Name:HAGGERTY, KIMBERLY MARIE
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:HAGGERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:M
Other - Last Name:RIZZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:78 CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-2118
Mailing Address - Country:US
Mailing Address - Phone:631-827-1515
Mailing Address - Fax:
Practice Address - Street 1:299 HALLOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1217
Practice Address - Country:US
Practice Address - Phone:631-473-4284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist