1114403482 NPI number — MRS. KIMBERLY DENIESE MCDANIEL AUTONOMOUS APRN

Table of content: MRS. KIMBERLY DENIESE MCDANIEL AUTONOMOUS APRN (NPI 1114403482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114403482 NPI number — MRS. KIMBERLY DENIESE MCDANIEL AUTONOMOUS APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDANIEL
Provider First Name:
KIMBERLY
Provider Middle Name:
DENIESE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
AUTONOMOUS APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEMAY
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
DENIESE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AUTONOMOUS APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114403482
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
680 VENETIAN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRITT ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32953-4116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-609-0654
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
775 E MERRITT ISLAND CSWY STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRITT ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32952-3311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-349-0642
Provider Business Practice Location Address Fax Number:
321-349-0643
Provider Enumeration Date:
07/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  9250594 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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