Provider Demographics
NPI:1619410867
Name:FRATESCHI, KIMBERLY
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:FRATESCHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:FRATESCHI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4754
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13221-4754
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4151 SPLIT ROCK RD
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-9716
Practice Address - Country:US
Practice Address - Phone:315-487-4656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026212-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist