Healthcare Provider Details

I. General information

NPI: 1336484385
Provider Name (Legal Business Name): KIMBERLY ANN ANSELMO CRNA, MSN, ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 N WICKHAM RD
MELBOURNE FL
32935-8625
US

IV. Provider business mailing address

321 FRANZING ST SW
PALM BAY FL
32908-1310
US

V. Phone/Fax

Practice location:
  • Phone: 321-752-1200
  • Fax:
Mailing address:
  • Phone: 321-427-6548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC-APN.0103889-C-CRNA
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9168349
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: