Basic Information
| Provider Information | |||||||||
| NPI: | 1720724701 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | KYLIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 416457 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443621735 | ||||||||
| FaxNumber: | 9732907495 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 MOUNT HOPE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKAWAY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078661654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739717507 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2022 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 26NJ01309000 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.