Provider Demographics
NPI:1922008184
Name:SWEET, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SWEET
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 1:85 S MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4561
Mailing Address - Country:US
Mailing Address - Phone:201-445-2830
Mailing Address - Fax:201-445-7471
Practice Address - Street 1:85 S MAPLE AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4561
Practice Address - Country:US
Practice Address - Phone:201-445-2830
Practice Address - Fax:201-445-7471
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00142300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00349290OtherRR MDCR #
NJQ49982Medicare UPIN
NJ093673WX5Medicare PIN