1053484147 NPI number — MS. KIM R MARTIN-WIDAWSKY ANPC

Table of content: MS. KIM R MARTIN-WIDAWSKY ANPC (NPI 1053484147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053484147 NPI number — MS. KIM R MARTIN-WIDAWSKY ANPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN-WIDAWSKY
Provider First Name:
KIM
Provider Middle Name:
R
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ANPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053484147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 625
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLENDALE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07401-0625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-394-3329
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 W MAPLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLENDALE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07401-1206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-394-3329
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WX0106X , with the licence number:  26NN06683300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WX0106X , with the licence number: 300344 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 26NN06683300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 300344 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 26NN06683300 . This is a "ADVANCE PRACTICE NURSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 300344 . This is a "RN ANP LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: F300344-1 . This is a "NURSE PRACTITIONER IN ADULT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".