Healthcare Provider Details

I. General information

NPI: 1861189185
Provider Name (Legal Business Name): KIMBERLY CORNELIUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 37TH ST S APT 3
SAINT PETERSBURG FL
33711-4561
US

IV. Provider business mailing address

4420 37TH ST S APT 3
SAINT PETERSBURG FL
33711-4561
US

V. Phone/Fax

Practice location:
  • Phone: 727-301-2234
  • Fax:
Mailing address:
  • Phone: 727-301-2234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCNA33400
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: