Healthcare Provider Details

I. General information

NPI: 1639444136
Provider Name (Legal Business Name): KIMBERLY ANN EDWARDS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 TREE BLVD STE 1
ST AUGUSTINE FL
32084-5719
US

IV. Provider business mailing address

15280 NW 79TH CT
MIAMI LAKES FL
33016-5789
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-4005
  • Fax: 904-824-4009
Mailing address:
  • Phone: 305-558-3724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106467
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: