Provider Demographics
NPI:1447420567
Name:FANIZZA, KIM
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:FANIZZA
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 1:189 BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3103
Mailing Address - Country:US
Mailing Address - Phone:718-979-4585
Mailing Address - Fax:
Practice Address - Street 1:189 BRYANT AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3103
Practice Address - Country:US
Practice Address - Phone:718-979-4585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042720-1183500000X
FLPS29107183500000X
NJ28R102325600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY042720-1OtherRPH STATE LICENSE NUMBER
FLPS29107OtherRPH LICENSE NUMBER
NJ28R102325600OtherRPH LICENSE NUMBER