MEDICARE: MRS. KIMBERLY ANN NAGORNIUK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	0019013136	VA

General Provider Information

NPI Number	:	1063953487
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY ANN NAGORNIUK

Provider Business Mailing Address
First Line	:	3201 CLUB HOUSE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-6503
Country	:	US
Telephone Number	:	757-403-0682
Fax Number	:

Provider Business Practice Location Address
First Line	:	325 FIRST COLONIAL RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-4665
Country	:	US
Telephone Number	:	757-403-0682
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2017
Last Update Date	:	03/17/2017

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