Provider Demographics
NPI:1114113305
Name:FONTANA, KIM ANN (RN REGISTERED NURSE)
Entity Type:Individual
Prefix:MISS
First Name:KIM
Middle Name:ANN
Last Name:FONTANA
Suffix:
Gender:F
Credentials:RN REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 LOW LANE
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-4511
Mailing Address - Country:US
Mailing Address - Phone:516-551-1383
Mailing Address - Fax:631-277-0081
Practice Address - Street 1:23 LOW LANE
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-4511
Practice Address - Country:US
Practice Address - Phone:516-551-1383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4813011163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01681061Medicaid