Provider Demographics
NPI:1013005289
Name:FALLON, KIM M (APN)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:FALLON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08721-1229
Mailing Address - Country:US
Mailing Address - Phone:732-349-5550
Mailing Address - Fax:732-505-1517
Practice Address - Street 1:160 ROUTE 9
Practice Address - Street 2:
Practice Address - City:BAYVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08721-1229
Practice Address - Country:US
Practice Address - Phone:732-349-5550
Practice Address - Fax:732-505-1517
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00062300363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0192881Medicaid