Provider Demographics
NPI:1205475746
Name:BACKMAN, KIM ELAINE (NP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:ELAINE
Last Name:BACKMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:ELAINE
Other - Last Name:BACKMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:100 FAIRWAY RD
Mailing Address - Street 2:
Mailing Address - City:LIDO BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4820
Mailing Address - Country:US
Mailing Address - Phone:516-244-6968
Mailing Address - Fax:
Practice Address - Street 1:2079 WANTAGH AVE STE 4
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3924
Practice Address - Country:US
Practice Address - Phone:516-244-6968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY402879363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health