Provider Demographics
NPI:1235256900
Name:PESANIELLO, KIMBERLY HOGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:HOGAN
Last Name:PESANIELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21863-1229
Mailing Address - Country:US
Mailing Address - Phone:757-894-3118
Mailing Address - Fax:
Practice Address - Street 1:105 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:MD
Practice Address - Zip Code:21863-1229
Practice Address - Country:US
Practice Address - Phone:757-894-3118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00415452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF64202Medicare UPIN