Provider Demographics
NPI:1538252390
Name:BAGLEY, KIM MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MARIE
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 GILBERT STREET
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14554
Mailing Address - Country:US
Mailing Address - Phone:585-554-4282
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642
Practice Address - Country:US
Practice Address - Phone:585-275-2975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302662363LA2200X
NYF3026621363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health