Provider Demographics
NPI:1053484147
Name:MARTIN-WIDAWSKY, KIM R (ANPC)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:R
Last Name:MARTIN-WIDAWSKY
Suffix:
Gender:F
Credentials:ANPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 625
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07401-0625
Mailing Address - Country:US
Mailing Address - Phone:201-394-3329
Mailing Address - Fax:
Practice Address - Street 1:77 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:NJ
Practice Address - Zip Code:07401-1206
Practice Address - Country:US
Practice Address - Phone:201-394-3329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN06683300163WX0106X, 363L00000X
NY300344163WX0106X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WX0106XNursing Service ProvidersRegistered NurseOccupational Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NN06683300OtherADVANCE PRACTICE NURSE
NY300344OtherRN ANP LICENSE
NYF300344-1OtherNURSE PRACTITIONER IN ADULT HEALTH