Healthcare Provider Details

I. General information

NPI: 1619231958
Provider Name (Legal Business Name): KIMBERLY MICHELE SEXTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7998 STATE ROUTE 31
BRIDGEPORT NY
13030-8436
US

IV. Provider business mailing address

7998 STATE ROUTE 31
BRIDGEPORT NY
13030-8436
US

V. Phone/Fax

Practice location:
  • Phone: 315-633-0073
  • Fax: 315-633-2759
Mailing address:
  • Phone: 315-633-0073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number056776
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: