MEDICARE: KIMBERLY SAMPLE RNFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WR0006X	Registered Nurse First Assistant	RN2960732	FL

General Provider Information

NPI Number	:	1972804276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY SAMPLE RNFA

Provider Business Mailing Address
First Line	:	1201 TABIT RD
Second Line	:
City	:	BELLE GLADE
State	:	FL
Zip	:	33430-4556
Country	:	US
Telephone Number	:	561-755-3299
Fax Number	:

Provider Business Practice Location Address
First Line	:	39200 HOOKER HWY
Second Line	:
City	:	BELLE GLADE
State	:	FL
Zip	:	33430-5368
Country	:	US
Telephone Number	:	561-755-3299
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2010
Last Update Date	:	11/03/2010

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