Basic Information
| Provider Information | |||||||||
| NPI: | 1932633971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAIGNEAULT | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NOVICKE | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7 HOLLAND WAY FL 1 | ||||||||
| Address2: | |||||||||
| City: | EXETER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038332997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037750000 | ||||||||
| FaxNumber: | 6037782491 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 HAMPTON RD BLDG 3 | ||||||||
| Address2: | |||||||||
| City: | EXETER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038334831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037750000 | ||||||||
| FaxNumber: | 6037782491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2017 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 053516-23 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3107956 | 05 | NH | MEDICAID |