Healthcare Provider Details

I. General information

NPI: 1386837631
Provider Name (Legal Business Name): KIM RIDENHOUR RN, MSN, MBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 13TH CT SW
LARGO FL
33770-4472
US

IV. Provider business mailing address

10 000 BAY PINES BLVD.
BAY PINES FL
33744
US

V. Phone/Fax

Practice location:
  • Phone: 727-398-6661
  • Fax:
Mailing address:
  • Phone: 727-398-6661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN3206512
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: