Provider Demographics
NPI:1639618275
Name:TARDALO, KIMBERLY ANNE (FNP)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:TARDALO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 KENT AVE APT 708
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11249-5290
Mailing Address - Country:US
Mailing Address - Phone:201-320-5732
Mailing Address - Fax:
Practice Address - Street 1:175 KENT AVE APT 708
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-5290
Practice Address - Country:US
Practice Address - Phone:201-320-5732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY675235163W00000X
NY341458363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse