Healthcare Provider Details

I. General information

NPI: 1053553974
Provider Name (Legal Business Name): KIMBERLY SIMON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 VILLAGE SQUARE PKWY STE 202
FLEMING ISLAND FL
32003-6351
US

IV. Provider business mailing address

PO BOX 746649
ATLANTA GA
30374-6649
US

V. Phone/Fax

Practice location:
  • Phone: 904-516-1880
  • Fax: 904-516-1885
Mailing address:
  • Phone: 904-376-4400
  • Fax: 904-391-5595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9263507
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9263507
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN9263507
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: