Provider Demographics
NPI:1518006089
Name:BURGNON, KIMBERLY (MED)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:BURGNON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 CALAFUT CT
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7200
Mailing Address - Country:US
Mailing Address - Phone:407-810-7674
Mailing Address - Fax:407-977-9094
Practice Address - Street 1:561 E MITCHELL HAMMOCK RD STE 200
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-5526
Practice Address - Country:US
Practice Address - Phone:407-810-7674
Practice Address - Fax:321-348-0118
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9095101YM0800X
FLIMH 4726101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL762539100Medicaid