=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124989686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY MARINO-MICHEEL DOM,LAC,AP,DIPL,RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2025
-----------------------------------------------------
Last Update Date | 11/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 N INDIANA AVE
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34223-2728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-812-0777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1970 FORKED CREEK DR
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34223-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-812-0777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 202D00000X
-----------------------------------------------------
Taxonomy Name | Integrative Medicine Physician
-----------------------------------------------------
License Number | L.AC4693
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------