Provider Demographics
NPI:1235919465
Name:STEVENS, KIMBERLY SUE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 COUNTY ROUTE 11 LOT 154
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:13167-4114
Mailing Address - Country:US
Mailing Address - Phone:315-882-0489
Mailing Address - Fax:
Practice Address - Street 1:620 MADISON ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2338
Practice Address - Country:US
Practice Address - Phone:315-426-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188178164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty