Basic Information
| Provider Information | |||||||||
| NPI: | 1154912988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARKER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | OPTICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 146 ARSENAL ST STE 8 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157860983 | ||||||||
| FaxNumber: | 3157860994 | ||||||||
| Practice Location | |||||||||
| Address1: | 146 ARSENAL ST STE 8 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157860983 | ||||||||
| FaxNumber: | 3157860994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2021 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | 009726-01 | NY | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.