Provider Demographics
NPI:1518640648
Name:O'HALLORAN, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:O'HALLORAN
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 1:255 HOPRIVER RD
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:CT
Mailing Address - Zip Code:06043-7411
Mailing Address - Country:US
Mailing Address - Phone:860-268-9318
Mailing Address - Fax:
Practice Address - Street 1:255 HOPRIVER RD
Practice Address - Street 2:
Practice Address - City:BOLTON
Practice Address - State:CT
Practice Address - Zip Code:06043-7411
Practice Address - Country:US
Practice Address - Phone:860-268-9318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3789172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver