MEDICARE: KYLIE ANN JIMENEZ FNP-C

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	363LF0000X	Family Nurse Practitioner	26NJ01309000	NJ

General Provider Information

NPI Number	:	1720724701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLIE ANN JIMENEZ FNP-C

Provider Business Mailing Address
First Line	:	PO BOX 416457
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02241-5604
Country	:	US
Telephone Number	:	844-362-1735
Fax Number	:	973-290-7495

Provider Business Practice Location Address
First Line	:	333 MOUNT HOPE AVE
Second Line	:
City	:	ROCKAWAY
State	:	NJ
Zip	:	07866-1654
Country	:	US
Telephone Number	:	973-971-7507
Fax Number	:

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

Provider Enumeration Date	:	05/11/2022
Last Update Date	:	07/29/2022

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