Provider Demographics
NPI:1518190826
Name:SOTHERDEN, KIMBERLY ANNE (LPN)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:SOTHERDEN
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 1:47 TRELIGN DR
Mailing Address - Street 2:APT 4
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-3261
Mailing Address - Country:US
Mailing Address - Phone:315-383-2560
Mailing Address - Fax:
Practice Address - Street 1:47 TRELIGN DR
Practice Address - Street 2:APT 4
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-3261
Practice Address - Country:US
Practice Address - Phone:315-383-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295105164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse