Healthcare Provider Details

I. General information

NPI: 1497273429
Provider Name (Legal Business Name): KIMBERLY A O'DONNELL ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5742 BOOTH RD STE A
JACKSONVILLE FL
32207-5982
US

IV. Provider business mailing address

7015 A C SKINNER PKWY STE 1
JACKSONVILLE FL
32256-6932
US

V. Phone/Fax

Practice location:
  • Phone: 907-739-7779
  • Fax: 904-739-7771
Mailing address:
  • Phone: 904-363-2113
  • Fax: 904-363-2606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN9297153
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: