Provider Demographics
NPI:1235603259
Name:WAKS, KIMBERLY JOY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOY
Last Name:WAKS
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 1:1121 TOWN COLONY DR BLDG 19
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-5923
Mailing Address - Country:US
Mailing Address - Phone:516-306-2353
Mailing Address - Fax:
Practice Address - Street 1:270 FARMINGTON AVE STE 309
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1953
Practice Address - Country:US
Practice Address - Phone:860-677-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-12
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5498363A00000X
VA0110-007506363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program