Provider Demographics
NPI:1740929165
Name:KINBLOM, SHARON ANN
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:ANN
Last Name:KINBLOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ILENE DR
Mailing Address - Street 2:
Mailing Address - City:MORRISONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12962-3405
Mailing Address - Country:US
Mailing Address - Phone:518-222-3061
Mailing Address - Fax:
Practice Address - Street 1:20 ILENE DR
Practice Address - Street 2:
Practice Address - City:MORRISONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12962-3405
Practice Address - Country:US
Practice Address - Phone:518-222-3061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X, 171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program