Basic Information
| Provider Information | |||||||||
| NPI: | 1255984662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POPE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 ROUTE 112 BLDG 4 | ||||||||
| Address2: | SUITE101 | ||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6315096559 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 BAYVIEW CT | ||||||||
| Address2: | |||||||||
| City: | SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117334003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175260629 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2019 | ||||||||
| LastUpdateDate: | 08/21/2019 | ||||||||
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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 | 344779 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.