Healthcare Provider Details

I. General information

NPI: 1972755775
Provider Name (Legal Business Name): MRS. KIMBERLY BRUNDIDGE I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2008
Last Update Date: 10/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 S MAIN ST
HAVANA FL
32333-2134
US

IV. Provider business mailing address

411 S MAIN ST
HAVANA FL
32333-2134
US

V. Phone/Fax

Practice location:
  • Phone: 850-879-1154
  • Fax:
Mailing address:
  • Phone: 850-879-1154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: