Healthcare Provider Details

I. General information

NPI: 1275378291
Provider Name (Legal Business Name): KIMBERLY PAIGE WALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY PAIGE WESTOVER

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MEMORIAL MEDICAL PKWY
DAYTONA BEACH FL
32117-5167
US

IV. Provider business mailing address

4501 NETTLE CREEK CT
PORT ORANGE FL
32127-4909
US

V. Phone/Fax

Practice location:
  • Phone: 386-231-6000
  • Fax:
Mailing address:
  • Phone: 814-316-6105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number58528
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: