Provider Demographics
NPI:1407046139
Name:GREGG, KIM ANSONIA (RN)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:ANSONIA
Last Name:GREGG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:KIM
Other - Middle Name:ANSONIA
Other - Last Name:GREGG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:46 BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-1715
Mailing Address - Country:US
Mailing Address - Phone:631-920-0751
Mailing Address - Fax:
Practice Address - Street 1:46 BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-1715
Practice Address - Country:US
Practice Address - Phone:631-920-0751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02841078164W00000X
NY712329-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse