Provider Demographics
NPI:1255984662
Name:POPE, KIMBERLY ANN (FNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:POPE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 112 BLDG 4
Mailing Address - Street 2:SUITE101
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776
Mailing Address - Country:US
Mailing Address - Phone:631-751-3000
Mailing Address - Fax:631-509-6559
Practice Address - Street 1:3 BAYVIEW CT
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-4003
Practice Address - Country:US
Practice Address - Phone:917-526-0629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344779363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily