Healthcare Provider Details

I. General information

NPI: 1730727314
Provider Name (Legal Business Name): KIMBERLY DIANE MACKAY NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2019
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

PO BOX 44008
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-3508
  • Fax: 904-244-4301
Mailing address:
  • Phone: 904-244-3508
  • Fax: 904-244-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number683428
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberAPRN11030321
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: