Provider Demographics
NPI:1548611221
Name:COLON, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:COLON
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 1:3165 DECATUR AVE
Mailing Address - Street 2:APT 7A
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-4512
Mailing Address - Country:US
Mailing Address - Phone:917-604-5485
Mailing Address - Fax:
Practice Address - Street 1:3165 DECATUR AVE
Practice Address - Street 2:APT 7A
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-4512
Practice Address - Country:US
Practice Address - Phone:917-604-5485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY709394163W00000X
NY402288363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse