Healthcare Provider Details

I. General information

NPI: 1871030841
Provider Name (Legal Business Name): KIMBERLY RET APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1992 LEWIS TURNER BLVD STE 1171
FORT WALTON BEACH FL
32547-1255
US

IV. Provider business mailing address

1992 LEWIS TURNER BLVD STE 1171
FORT WALTON BEACH FL
32547-1255
US

V. Phone/Fax

Practice location:
  • Phone: 850-343-5602
  • Fax: 850-979-8754
Mailing address:
  • Phone: 850-343-5602
  • Fax: 850-979-8754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN9391797
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN9391797
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: