Provider Demographics
NPI:1578629028
Name:SMALL, KIMBERLY (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 NORTH ST STE 221
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-5133
Mailing Address - Country:US
Mailing Address - Phone:508-862-7777
Mailing Address - Fax:
Practice Address - Street 1:5 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649-3464
Practice Address - Country:US
Practice Address - Phone:508-778-4777
Practice Address - Fax:508-771-9555
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160735363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NP2292OtherBCBS
MAP02242Medicare UPIN
MAQX6641Medicare PIN