1518932912 NPI number — KIMBERLY SUE NICHOLS P.T, ATC

Table of content: KIMBERLY SUE NICHOLS P.T, ATC (NPI 1518932912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518932912 NPI number — KIMBERLY SUE NICHOLS P.T, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
KIMBERLY
Provider Middle Name:
SUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T, ATC
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:
1518932912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
92 WEST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROCKPORT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14420-1306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-637-0790
Provider Business Mailing Address Fax Number:
585-637-3572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
880 ELMGROVE RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14624-1320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-247-8535
Provider Business Practice Location Address Fax Number:
585-247-1957
Provider Enumeration Date:
02/20/2006

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: 225100000X , with the licence number:  000884 , 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: 7695330 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110575FT . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com