Provider Demographics
NPI:1306846555
Name:VAN WICKLEN, KYM (CRNA)
Entity Type:Individual
Prefix:
First Name:KYM
Middle Name:
Last Name:VAN WICKLEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KYM
Other - Middle Name:
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:68 S SERVICE RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2354
Mailing Address - Country:US
Mailing Address - Phone:516-945-3000
Mailing Address - Fax:
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3816
Practice Address - Country:US
Practice Address - Phone:516-562-4887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY417417367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR6A961Medicare ID - Type UnspecifiedEMPIRE MEDICARE
NY0422BJMedicare ID - Type UnspecifiedGHI MEDICARE