Provider Demographics
NPI:1861875080
Name:CIACCIA, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CIACCIA
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 1:10101 ROCKAWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11417-2228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10101 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11417-2228
Practice Address - Country:US
Practice Address - Phone:917-566-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY687399163W00000X
NY382611363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse