Healthcare Provider Details

I. General information

NPI: 1720911894
Provider Name (Legal Business Name): KIMARLEY ANDRE GAYLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 RATZER RD
WAYNE NJ
07470-5440
US

IV. Provider business mailing address

197 RATZER RD
WAYNE NJ
07470-5440
US

V. Phone/Fax

Practice location:
  • Phone: 347-585-4754
  • Fax: 347-585-4754
Mailing address:
  • Phone: 347-585-4754
  • Fax: 347-585-4754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: