Provider Demographics
NPI:1942799259
Name:RAJMOHAN, KIMBERLY TARA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:TARA
Last Name:RAJMOHAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 DOGWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CLIFFWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07721-1273
Mailing Address - Country:US
Mailing Address - Phone:732-737-5018
Mailing Address - Fax:
Practice Address - Street 1:520 E 70TH ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:646-962-7950
Practice Address - Fax:212-746-6678
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF342940-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily