Healthcare Provider Details

I. General information

NPI: 1629942636
Provider Name (Legal Business Name): KIMBERLY CONNELLY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MAPLE AVE
WARWICK NY
10990-1028
US

IV. Provider business mailing address

3 NOVISKI LN
PINE ISLAND NY
10969-1926
US

V. Phone/Fax

Practice location:
  • Phone: 845-323-2220
  • Fax:
Mailing address:
  • Phone: 845-323-2220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number439350
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: