Healthcare Provider Details

I. General information

NPI: 1225933351
Provider Name (Legal Business Name): KIMBERLY EDEISHA PENNERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 WASHINGTON BLVD NW
LAKE PLACID FL
33852-8312
US

IV. Provider business mailing address

750 WASHINGTON BLVD NW
LAKE PLACID FL
33852-8312
US

V. Phone/Fax

Practice location:
  • Phone: 863-664-1044
  • Fax:
Mailing address:
  • Phone: 863-664-1044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: