Provider Demographics
NPI:1619484789
Name:DAVILA, KIMBERLY-ANN
Entity Type:Individual
Prefix:
First Name:KIMBERLY-ANN
Middle Name:
Last Name:DAVILA
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 1:20 DARRELL ST
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-5514
Mailing Address - Country:US
Mailing Address - Phone:631-278-3443
Mailing Address - Fax:
Practice Address - Street 1:21 SWEET HOLLOW RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-6530
Practice Address - Country:US
Practice Address - Phone:631-760-7972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027141235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist