Healthcare Provider Details

I. General information

NPI: 1972346617
Provider Name (Legal Business Name): KIMBERLY MICHELLE ORTIZ DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4866 BIG ISLAND DR
JACKSONVILLE FL
32246-7498
US

IV. Provider business mailing address

12793 QUINCY BAY DR
JACKSONVILLE FL
32224-8515
US

V. Phone/Fax

Practice location:
  • Phone: 904-652-0652
  • Fax:
Mailing address:
  • Phone: 561-665-1366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11033482
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: