Provider Demographics
NPI:1477546000
Name:VENABLE, KIMBERLY L (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:VENABLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519A E BLOOMINGDALE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8105
Mailing Address - Country:US
Mailing Address - Phone:813-655-4100
Mailing Address - Fax:813-655-1775
Practice Address - Street 1:519A E BLOOMINGDALE AVE STE A
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8105
Practice Address - Country:US
Practice Address - Phone:813-655-4100
Practice Address - Fax:813-655-1775
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00857363A00000X
FLPA9110447363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX284052201Medicaid
TXTXB111711Medicare PIN
TX284052201Medicaid
TXTXB126511Medicare PIN
TXQ46478Medicare UPIN
TX8L2347Medicare PIN
TX8D6396Medicare ID - Type Unspecified
TX8L2346Medicare PIN