Provider Demographics
NPI:1336109651
Name:KOVALICK, KIMBERLY ANN M (DO)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY ANN
Middle Name:M
Last Name:KOVALICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-3034
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:560 PIERCE ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5716
Practice Address - Country:US
Practice Address - Phone:570-283-2161
Practice Address - Fax:570-714-0670
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009116L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001706740Medicaid
PA013937Medicare ID - Type Unspecified