Provider Demographics
NPI:1073779385
Name:STOUTENBURG, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:STOUTENBURG
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 1:12 GLENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-2238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5297 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-7504
Practice Address - Country:US
Practice Address - Phone:585-394-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260768163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse