Healthcare Provider Details

I. General information

NPI: 1407296734
Provider Name (Legal Business Name): KIM CANTELLO-BAKER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 N WICKHAM RD STE 309
MELBOURNE FL
32935-8661
US

IV. Provider business mailing address

240 N WICKHAM RD STE 309
MELBOURNE FL
32935-8661
US

V. Phone/Fax

Practice location:
  • Phone: 321-752-1630
  • Fax: 321-690-6578
Mailing address:
  • Phone: 321-752-1630
  • Fax: 321-690-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN9250144
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN9250144
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9250144
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: