Healthcare Provider Details

I. General information

NPI: 1720926587
Provider Name (Legal Business Name): KIMBERLY MICHELLE WETHERELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 GENESEE RD
ARCADE NY
14009-9712
US

IV. Provider business mailing address

1179 GENESEE RD
ARCADE NY
14009-9712
US

V. Phone/Fax

Practice location:
  • Phone: 407-431-5876
  • Fax:
Mailing address:
  • Phone: 407-431-5876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SL0600X
TaxonomyLong-Term Care Clinical Nurse Specialist
License NumberNYFL04588320R
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: