MEDICARE: MS. KIM DAMARIS YORK NURSE PRACTITIONER

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	363LA2200X	Adult Health Nurse Practitioner	2015030542	MO

General Provider Information

NPI Number	:	1205207768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIM DAMARIS YORK NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	70 CEDAR BLUFF DR APT 19
Second Line	:
City	:	LAKE ST LOUIS
State	:	MO
Zip	:	63367-2809
Country	:	US
Telephone Number	:	636-887-2125
Fax Number	:

Provider Business Practice Location Address
First Line	:	70 CEDAR BLUFF DR APT 19
Second Line	:
City	:	LAKE ST LOUIS
State	:	MO
Zip	:	63367-2809
Country	:	US
Telephone Number	:	636-887-2125
Fax Number	:

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

Provider Enumeration Date	:	10/09/2015
Last Update Date	:	10/09/2015

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