Provider Demographics
NPI:1407431521
Name:HUMPHREY, KIM (LPN)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:HUMPHREY
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 1:213 LIBERTY ST APT 101
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-1157
Mailing Address - Country:US
Mailing Address - Phone:607-661-2742
Mailing Address - Fax:
Practice Address - Street 1:4612 MILLENNIUM DR
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:NY
Practice Address - Zip Code:14454-1197
Practice Address - Country:US
Practice Address - Phone:585-991-5012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310662-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY161039939Medicaid
161039939OtherALL OTHER INSURANCES