Provider Demographics
NPI:1518599612
Name:GONG, KIMBERLY Y (BA, MS)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:Y
Last Name:GONG
Suffix:
Gender:F
Credentials:BA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CONWAY DR APT 202
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-3840
Mailing Address - Country:US
Mailing Address - Phone:973-229-7137
Mailing Address - Fax:
Practice Address - Street 1:25 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:KENVIL
Practice Address - State:NJ
Practice Address - Zip Code:07847-2500
Practice Address - Country:US
Practice Address - Phone:973-229-7137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer