Provider Demographics
NPI:1942358791
Name:FITZGERALD, KIM L (RN-NP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:RN-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MERRIMAC ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-0379
Mailing Address - Country:US
Mailing Address - Phone:617-283-8581
Mailing Address - Fax:603-737-5947
Practice Address - Street 1:150 MERRIMAC ST
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-2357
Practice Address - Country:US
Practice Address - Phone:617-283-8581
Practice Address - Fax:603-737-5947
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211761363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1312294Medicaid
MANP4735Medicare ID - Type Unspecified