Healthcare Provider Details

I. General information

NPI: 1649872292
Provider Name (Legal Business Name): KIMBERLY IVETTE KUILAN SLPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 S 23RD ST STE 2
FORT PIERCE FL
34950-4830
US

IV. Provider business mailing address

1503 SE WALTON LAKES DR
PORT SAINT LUCIE FL
34952-5106
US

V. Phone/Fax

Practice location:
  • Phone: 772-464-3303
  • Fax:
Mailing address:
  • Phone: 787-454-1029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number4206
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: