Healthcare Provider Details

I. General information

NPI: 1023827334
Provider Name (Legal Business Name): KIMBERLY KOTTAS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2025
Last Update Date: 01/01/2025
Certification Date: 01/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 BROADWAY PH
NEW YORK NY
10012-2614
US

IV. Provider business mailing address

632 BROADWAY PH
NEW YORK NY
10012-2614
US

V. Phone/Fax

Practice location:
  • Phone: 800-731-4254
  • Fax:
Mailing address:
  • Phone: 800-731-4254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number89750
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: