Basic Information
| Provider Information | |||||||||
| NPI: | 1245503234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDS | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NPP & FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TODD | ||||||||
| OtherFirstName: | KIM | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | NPP & FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4 COMMERCE LN | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136173739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153868191 | ||||||||
| FaxNumber: | 3153861410 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 COMMERCE LN | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136173739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153868191 | ||||||||
| FaxNumber: | 3153861410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2012 | ||||||||
| LastUpdateDate: | 02/27/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 33 332874 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 40 401381 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 40401381 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LF0000X | 33332874 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 01995615 | 05 | NY | MEDICAID |