Provider Demographics
NPI:1033687850
Name:ANNICELLI, KIMBERLY A
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:ANNICELLI
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 1:79 CROWN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2801
Mailing Address - Country:US
Mailing Address - Phone:631-949-5894
Mailing Address - Fax:
Practice Address - Street 1:79 CROWN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2801
Practice Address - Country:US
Practice Address - Phone:631-949-5894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency