Provider Demographics
NPI:1255545257
Name:MOTT, KIMBERLY ANN (BA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:MOTT
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 SINCLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:LANOKA HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08734-1837
Mailing Address - Country:US
Mailing Address - Phone:609-312-7649
Mailing Address - Fax:
Practice Address - Street 1:116 SINCLAIR AVE
Practice Address - Street 2:
Practice Address - City:LANOKA HARBOR
Practice Address - State:NJ
Practice Address - Zip Code:08734-1837
Practice Address - Country:US
Practice Address - Phone:609-312-7649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0094692Medicaid