1861755175 NPI number — MRS. KIMBERLY ANN WOLFERT MSED

Table of content: MRS. KIMBERLY ANN WOLFERT MSED (NPI 1861755175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861755175 NPI number — MRS. KIMBERLY ANN WOLFERT MSED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLFERT
Provider First Name:
KIMBERLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSED
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:
1861755175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
56 NADINE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT JEFFERSON STATION
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11776-2851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-476-5778
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2350 WESTCHESTER AVE
Provider Second Line Business Practice Location Address:
108
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-597-5588
Provider Business Practice Location Address Fax Number:
718-823-5494
Provider Enumeration Date:
06/21/2012

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: 174400000X , 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)





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