Basic Information
| Provider Information | |||||||||
| NPI: | 1992369490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIMANI | ||||||||
| FirstName: | VERONICAH | ||||||||
| MiddleName: | NJAMBI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | B.ED | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | N/A | ||||||||
| OtherFirstName: | N/A | ||||||||
| OtherMiddleName: | N/A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | N/A | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 109 OAK ST STE G20 | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024641492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176585611 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 23 PRATT AVE APT 11 | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018511554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783193744 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2019 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 376K00000X | CNA-125452 | MA | Y | Nursing Service Related Providers | Nurse's Aide |
ID Information
| ID | Type | State | Issuer | Description | 065-714-071 | 05 | MA | MEDICAID | S16162222 | 01 | MA | DRIVING LICENSE | OTHER | S16162222 | 01 | MA | DRIVERS LICENSE | OTHER |