Provider Demographics
NPI:1417214446
Name:PREMO, KIM M (RN)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:M
Last Name:PREMO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:KIM
Other - Middle Name:M
Other - Last Name:MULVERHILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:524 EAST MAIN STREET
Mailing Address - Street 2:FLANDERS ELEMENTARY SCHOOL
Mailing Address - City:MALANE
Mailing Address - State:NY
Mailing Address - Zip Code:12953
Mailing Address - Country:US
Mailing Address - Phone:518-483-7803
Mailing Address - Fax:518-483-9491
Practice Address - Street 1:524 EAST MAIN STREET
Practice Address - Street 2:FLANDERS ELEMENTARY SCHOOL
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953
Practice Address - Country:US
Practice Address - Phone:518-483-7803
Practice Address - Fax:518-483-9491
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY381242-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool