Provider Demographics
NPI:1992223101
Name:NIESE, KIMBERLY TRACEY (SPECIAL EDUCATION)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:TRACEY
Last Name:NIESE
Suffix:
Gender:F
Credentials:SPECIAL EDUCATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 SAGAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:MOHEGAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10547-1348
Mailing Address - Country:US
Mailing Address - Phone:454-947-6938
Mailing Address - Fax:
Practice Address - Street 1:3510 SAAGMORE AVENUE
Practice Address - Street 2:
Practice Address - City:MOHEGAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:10547-1054
Practice Address - Country:US
Practice Address - Phone:454-947-6938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY879626174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist