Provider Demographics
NPI:1750163705
Name:MCCLINTOCK-WALLA, KIMBERLY THERESA (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:THERESA
Last Name:MCCLINTOCK-WALLA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:67 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:10965-2444
Mailing Address - Country:US
Mailing Address - Phone:845-368-0800
Mailing Address - Fax:845-368-0810
Practice Address - Street 1:67 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:NY
Practice Address - Zip Code:10965-2444
Practice Address - Country:US
Practice Address - Phone:845-368-0800
Practice Address - Fax:845-368-0810
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY311577208VP0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine