Provider Demographics
NPI:1962802132
Name:SPRAGUE, KIMBERLY JEAN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEAN
Last Name:SPRAGUE
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 1:5425 TOPSFIELD LN
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-8608
Mailing Address - Country:US
Mailing Address - Phone:716-307-1971
Mailing Address - Fax:
Practice Address - Street 1:5425 TOPSFIELD LN
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:NY
Practice Address - Zip Code:13041-8608
Practice Address - Country:US
Practice Address - Phone:716-307-1971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency