Provider Demographics
NPI:1508958703
Name:VERNON, KIM MABEL
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MABEL
Last Name:VERNON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KIM
Other - Middle Name:MABEL
Other - Last Name:LENTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1230 CHEWS LANDING RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL SPRINGS
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-2804
Mailing Address - Country:US
Mailing Address - Phone:856-784-1222
Mailing Address - Fax:856-784-0068
Practice Address - Street 1:1230 CHEWS LANDING RD
Practice Address - Street 2:
Practice Address - City:LAUREL SPRINGS
Practice Address - State:NJ
Practice Address - Zip Code:08021-2804
Practice Address - Country:US
Practice Address - Phone:856-784-1222
Practice Address - Fax:856-784-0068
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD-2181156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician