Provider Demographics
NPI:1417670399
Name:BUCHANAN, KIMBERLY DIANE
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DIANE
Last Name:BUCHANAN
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 1:724 NE COSMOS DRIVE
Mailing Address - Street 2:
Mailing Address - City:PINETTA
Mailing Address - State:FL
Mailing Address - Zip Code:32350
Mailing Address - Country:US
Mailing Address - Phone:850-673-1778
Mailing Address - Fax:
Practice Address - Street 1:724 NE COSMOS DRIVE
Practice Address - Street 2:
Practice Address - City:PINETTA
Practice Address - State:FL
Practice Address - Zip Code:32350
Practice Address - Country:US
Practice Address - Phone:850-673-1778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15726235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist