Healthcare Provider Details

I. General information

NPI: 1689207680
Provider Name (Legal Business Name): KIMBERLY ANN BALLERINO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8956 TURKEY LAKE RD
ORLANDO FL
32819-7327
US

IV. Provider business mailing address

5023 ROCK ROSE LOOP
SANFORD FL
32771-9203
US

V. Phone/Fax

Practice location:
  • Phone: 407-774-3325
  • Fax:
Mailing address:
  • Phone: 321-277-2943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11002068
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: