Provider Demographics
NPI:1114403482
Name:MCDANIEL, KIMBERLY DENIESE (AUTONOMOUS APRN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DENIESE
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:AUTONOMOUS APRN
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DENIESE
Other - Last Name:LEMAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUTONOMOUS APRN
Mailing Address - Street 1:680 VENETIAN WAY
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4116
Mailing Address - Country:US
Mailing Address - Phone:321-609-0654
Mailing Address - Fax:
Practice Address - Street 1:775 E MERRITT ISLAND CSWY STE 115
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3311
Practice Address - Country:US
Practice Address - Phone:321-349-0642
Practice Address - Fax:321-349-0643
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9250594363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner