Provider Demographics
NPI:1184942682
Name:DZIKOWSKI, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:DZIKOWSKI
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 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:SUITE 1K
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 WARREN AVE
Practice Address - Street 2:SUITE 204205
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-2647
Practice Address - Country:US
Practice Address - Phone:570-326-8360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT000422L231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024776630001Medicaid
PA7390412OtherAETNA
PA826125OtherFIRST PRIORITY HEALTH
PA1406521OtherHIGHMARK BLUE SHIELD
PA826125OtherFIRST PRIORITY HEALTH