Provider Demographics
NPI:1659657864
Name:KIMICK, DONNA B (IBCLC, RLC)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:B
Last Name:KIMICK
Suffix:
Gender:F
Credentials:IBCLC, RLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 LAKESHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-3005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:232 LAKESHORE BLVD
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-3005
Practice Address - Country:US
Practice Address - Phone:516-799-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10421257174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN