Healthcare Provider Details

I. General information

NPI: 1275111270
Provider Name (Legal Business Name): BEVERLY AYALA-KINCAID APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9800 S HEALTHPARK DR STE 205
FORT MYERS FL
33908-3630
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-7130
  • Fax: 239-343-7185
Mailing address:
  • Phone: 239-343-7130
  • Fax: 239-343-7185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number9481037
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11027268
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: