=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508687443
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLEY LYNN HENDRICKS APRN, ACCNS-P
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2024
-----------------------------------------------------
Last Update Date | 10/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6000 US-98
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32512-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-505-6601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10006 DOROVAN DR
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32526-4559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-809-4744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Clinical Nurse Specialist
-----------------------------------------------------
License Number | 5285806-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------