Healthcare Provider Details

I. General information

NPI: 1376457473
Provider Name (Legal Business Name): KIMBERLY JOY PENN REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 PARKWOOD LN
HILTON NY
14468-1344
US

IV. Provider business mailing address

104 PARKWOOD LN
HILTON NY
14468-1344
US

V. Phone/Fax

Practice location:
  • Phone: 585-503-5200
  • Fax:
Mailing address:
  • Phone: 585-503-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberN44712
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: