Healthcare Provider Details

I. General information

NPI: 1669293916
Provider Name (Legal Business Name): KIMBERLY ANNE SLOAN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 STATE ST
WATERTOWN NY
13601-2839
US

IV. Provider business mailing address

5420 LUCKNOW DR
CLAY NY
13041-9709
US

V. Phone/Fax

Practice location:
  • Phone: 315-755-1251
  • Fax: 315-291-6601
Mailing address:
  • Phone: 315-256-8410
  • Fax: 315-291-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number407397
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number636163
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number636163
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number636163
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number636163
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: