Provider Demographics
NPI:1417610205
Name:ELMENDORF, KIMBERLEE A
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:A
Last Name:ELMENDORF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:12117-4109
Mailing Address - Country:US
Mailing Address - Phone:518-844-5781
Mailing Address - Fax:518-274-6511
Practice Address - Street 1:289 OAKWOOD AVE STE C
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182-1708
Practice Address - Country:US
Practice Address - Phone:518-274-6525
Practice Address - Fax:518-274-6511
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY660935163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse