{
"Npi": {
"NPI": "1407039449",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "WILDERMUTH",
"FirstName": "KIMBERLY",
"MiddleName": "ANNE",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "PHARMD",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "73 N MAIN ST",
"SecondLineMailingAddress": "BIG M SHOPPING CENTER",
"MailingAddressCityName": "BROCKPORT",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "14420-1648",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "585-637-1151",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "73 N MAIN ST",
"SecondLinePracticeLocationAddress": "BIG M SHOPPING CENTER",
"PracticeLocationAddressCityName": "BROCKPORT",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "14420-1648",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "585-637-1151",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "12/13/2007",
"LastUpdateDate": "02/19/2010",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "183500000X",
"TaxonomyName": "Pharmacist",
"LicenseNumber": "051620",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}