Provider Demographics
NPI:1740727312
Name:ANDERSON, KIMBERLY (LPN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 GIMINSKI DR
Mailing Address - Street 2:APARTMENT 1
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-1304
Mailing Address - Country:US
Mailing Address - Phone:315-289-9514
Mailing Address - Fax:
Practice Address - Street 1:102 GIMINSKI DR
Practice Address - Street 2:APARTMENT 1
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-1304
Practice Address - Country:US
Practice Address - Phone:315-289-9514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3083671164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse