Provider Demographics
NPI:1417507302
Name:PERALTA, KIMBERLEE A
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:A
Last Name:PERALTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5610 29TH STREET CIR E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-5322
Mailing Address - Country:US
Mailing Address - Phone:505-615-7435
Mailing Address - Fax:
Practice Address - Street 1:5610 29TH STREET CIR E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-5322
Practice Address - Country:US
Practice Address - Phone:505-615-7435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103087800Medicaid