Provider Demographics
NPI:1366413536
Name:STACK, KIMBERLY MARIE (PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:STACK
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:MORAVEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CRNA
Mailing Address - Street 1:954 ROUTE 146 STE 3
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3639
Mailing Address - Country:US
Mailing Address - Phone:518-952-4000
Mailing Address - Fax:833-974-2234
Practice Address - Street 1:954 ROUTE 146 STE 3
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3639
Practice Address - Country:US
Practice Address - Phone:518-952-4000
Practice Address - Fax:833-974-2234
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF402216363L00000X
VA0001125389367500000X
NY426056-1367500000X
NY402216363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered