Basic Information
| Provider Information | |||||||||
| NPI: | 1699967331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YORK | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHILLIPS | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870490130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525438 | ||||||||
| FaxNumber: | 5055525811 | ||||||||
| Practice Location | |||||||||
| Address1: | 1-40 EXIT 102 | ||||||||
| Address2: | |||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870490130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525438 | ||||||||
| FaxNumber: | 5055525811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 10/27/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 492058 | NY | N | Nursing Service Providers | Registered Nurse | 163WC1500X | 492058 | NY | Y | Nursing Service Providers | Registered Nurse | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 492058 | 01 | NY | NURSING | OTHER |