MEDICARE: KIM ANGELA BACCHUS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	713784	NY

General Provider Information

NPI Number	:	1023465499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM ANGELA BACCHUS RN

Provider Business Mailing Address
First Line	:	162 HERZL ST
Second Line	:	APT.2
City	:	BROOKLYN
State	:	NY
Zip	:	11212-4631
Country	:	US
Telephone Number	:	347-482-7281
Fax Number	:

Provider Business Practice Location Address
First Line	:	162 HERZL ST
Second Line	:	APT.2
City	:	BROOKLYN
State	:	NY
Zip	:	11212-4631
Country	:	US
Telephone Number	:	347-482-7281
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2016
Last Update Date	:	05/16/2016

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