1942829510 NPI number — KIMBERLY J MEDINA RN

Table of content: KIMBERLY J MEDINA RN (NPI 1942829510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942829510 NPI number — KIMBERLY J MEDINA RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA
Provider First Name:
KIMBERLY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN
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:
1942829510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 WILLOW CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROMWELL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06416-1737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-225-1959
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 YORK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06510-3220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-688-4242
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2020

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: 163W00000X , with the licence number:  RN641567 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163W00000X , with the licence number: 150584 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WC0200X , with the licence number: RN641567 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: RN2307770 . This is a "MA BON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: RN641567 . This is a "PA BON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 150584 . This is a "CT BON" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com