MEDICARE: MRS. KIM FANIZZA

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	183500000X	Pharmacist	042720-1	NY
2	183500000X	Pharmacist	PS29107	FL
3	183500000X	Pharmacist	28R102325600	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	042720-1	OTHER	NY	RPH STATE LICENSE NUMBER
2	PS29107	OTHER	FL	RPH LICENSE NUMBER
3	28R102325600	OTHER	NJ	RPH LICENSE NUMBER

General Provider Information

NPI Number	:	1447420567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIM FANIZZA

Provider Business Mailing Address
First Line	:	189 BRYANT AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-3103
Country	:	US
Telephone Number	:	718-979-4585
Fax Number	:

Provider Business Practice Location Address
First Line	:	189 BRYANT AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-3103
Country	:	US
Telephone Number	:	718-979-4585
Fax Number	:

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

Provider Enumeration Date	:	03/04/2008
Last Update Date	:	03/04/2008

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