Provider Demographics
NPI:1467865105
Name:WATERBURY, KIMBERLY H (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:H
Last Name:WATERBURY
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 1:106 NEW HWY
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4217
Mailing Address - Country:US
Mailing Address - Phone:631-885-2040
Mailing Address - Fax:
Practice Address - Street 1:106 NEW HWY
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4217
Practice Address - Country:US
Practice Address - Phone:631-885-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY318598164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse