Provider Demographics
NPI:1245503234
Name:RICHARDS, KIM M (NPP & FNP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:NPP & FNP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:TODD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NPP & FNP
Mailing Address - Street 1:4 COMMERCE LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3739
Mailing Address - Country:US
Mailing Address - Phone:315-386-8191
Mailing Address - Fax:315-386-1410
Practice Address - Street 1:4 COMMERCE LN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3739
Practice Address - Country:US
Practice Address - Phone:315-386-8191
Practice Address - Fax:315-386-1410
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33 332874363LF0000X
NY40 401381363LP0808X
NY40401381363LP0808X
NY33332874363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995615Medicaid
NYAA0564Medicare PIN