Provider Demographics
NPI:1043848575
Name:KIMBERLY, CAITLIN ANN
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ANN
Last Name:KIMBERLY
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 1:40 AVALON DR UNIT 6331
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-8956
Mailing Address - Country:US
Mailing Address - Phone:814-381-6368
Mailing Address - Fax:
Practice Address - Street 1:40 AVALON DR UNIT 6331
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-8956
Practice Address - Country:US
Practice Address - Phone:814-381-6368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program