Healthcare Provider Details

I. General information

NPI: 1184517799
Provider Name (Legal Business Name): KALEY NOELLE WIMMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1887 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5530
US

IV. Provider business mailing address

450 APACHE TRL
MERRITT ISLAND FL
32953-7801
US

V. Phone/Fax

Practice location:
  • Phone: 772-463-0444
  • Fax:
Mailing address:
  • Phone: 321-480-5286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-441048
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: