Provider Demographics
NPI:1205207768
Name:YORK, KIM DAMARIS (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:DAMARIS
Last Name:YORK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 CEDAR BLUFF DR APT 19
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-2809
Mailing Address - Country:US
Mailing Address - Phone:636-887-2125
Mailing Address - Fax:
Practice Address - Street 1:70 CEDAR BLUFF DR APT 19
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-2809
Practice Address - Country:US
Practice Address - Phone:636-887-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015030542363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health