Provider Demographics
NPI:1639802416
Name:CREATER, KIMBERLY HARRIET
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:HARRIET
Last Name:CREATER
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 1:145 SARA LIB RD
Mailing Address - Street 2:
Mailing Address - City:FULTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12072-3245
Mailing Address - Country:US
Mailing Address - Phone:315-360-5819
Mailing Address - Fax:
Practice Address - Street 1:145 SARA LIB RD
Practice Address - Street 2:
Practice Address - City:FULTONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12072-3245
Practice Address - Country:US
Practice Address - Phone:315-360-5819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist