Provider Demographics
NPI:1750813788
Name:CHADDERDON, KIMBERLY NICOLE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:CHADDERDON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:NICOLE
Other - Last Name:CHADDERDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:50 VANTAGE POINT DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624
Mailing Address - Country:US
Mailing Address - Phone:585-352-7775
Mailing Address - Fax:585-352-7879
Practice Address - Street 1:50 VANTAGE POINT DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-1180
Practice Address - Country:US
Practice Address - Phone:585-352-7775
Practice Address - Fax:585-352-7879
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator