Provider Demographics
NPI:1003862855
Name:BETKER, KIMBERLEY A (FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:A
Last Name:BETKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:A
Other - Last Name:ODELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:6279 SOUTH HORNELL RD
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-9030
Mailing Address - Country:US
Mailing Address - Phone:607-661-4800
Mailing Address - Fax:607-661-4799
Practice Address - Street 1:6279 SOUTH HORNELL RD
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-9030
Practice Address - Country:US
Practice Address - Phone:607-661-4800
Practice Address - Fax:607-661-4799
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331172363LF0000X
NYF331172-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01790183Medicaid
NYU70284Medicare ID - Type Unspecified
NY01790183Medicaid