Provider Demographics
NPI:1053839191
Name:INCONTRERA, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:INCONTRERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 ARTHUR KILL RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 VEDDER AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1509
Practice Address - Country:US
Practice Address - Phone:718-370-9847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program