Provider Demographics
NPI:1225325921
Name:MERRILL, KIMBERLY HAGEMAN (NP-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:HAGEMAN
Last Name:MERRILL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8986 W CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BERKSHIRE
Mailing Address - State:NY
Mailing Address - Zip Code:13736-1342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 HARRISON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2161
Practice Address - Country:US
Practice Address - Phone:607-763-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305734363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health