Provider Demographics
NPI:1770115867
Name:DIGIACOMO, KIMBERLY MARIE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:DIGIACOMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 DAVIES PL APT 2
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-2283
Mailing Address - Country:US
Mailing Address - Phone:845-633-4079
Mailing Address - Fax:
Practice Address - Street 1:8 DAVIES PL APT 2
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-2283
Practice Address - Country:US
Practice Address - Phone:845-633-4079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334895-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY334895-1Medicaid