Provider Demographics
NPI:1760919526
Name:BOOKER, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BOOKER
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 1:13 ALMA AVE
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-1925
Mailing Address - Country:US
Mailing Address - Phone:631-885-4112
Mailing Address - Fax:
Practice Address - Street 1:13 ALMA AVE
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-1925
Practice Address - Country:US
Practice Address - Phone:631-885-4112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY319549-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse