Provider Demographics
NPI:1013912153
Name:DEJONG, ALIDA ANNE (NP)
Entity Type:Individual
Prefix:
First Name:ALIDA
Middle Name:ANNE
Last Name:DEJONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ALIDA
Other - Middle Name:ANNE
Other - Last Name:KIMMELMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1045 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2730
Mailing Address - Country:US
Mailing Address - Phone:315-472-4471
Mailing Address - Fax:315-472-1759
Practice Address - Street 1:1045 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2730
Practice Address - Country:US
Practice Address - Phone:315-472-4471
Practice Address - Fax:315-472-1759
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY482368-1163WG0000X
NYF302146-1363LA2200X
NYF333173-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02629216Medicaid
NYP80013Medicare UPIN
NY02629216Medicaid