Provider Demographics
NPI:1497273429
Name:O'DONNELL, KIMBERLY A (ARNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7015 A C SKINNER PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6932
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:904-363-2606
Practice Address - Street 1:5742 BOOTH RD STE A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5982
Practice Address - Country:US
Practice Address - Phone:907-739-7779
Practice Address - Fax:904-739-7771
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9297153363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJC682ZOtherMEDICARE
FL022227700Medicaid
FL5QPBYOtherFLORIDA BLUE
FLP02352086OtherRAILROAD MEDICARE