Provider Demographics
NPI:1992903983
Name:DEFATTA, KIMBERLY ANN (PNP)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:ANN
Last Name:DEFATTA
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:DEFATTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PNP
Mailing Address - Street 1:5631 226TH ST
Mailing Address - Street 2:APT 1
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8268 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1121
Practice Address - Country:US
Practice Address - Phone:718-883-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381894-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics