Provider Demographics
NPI:1518235159
Name:JEROME, KIMBERLY ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:JEROME
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:PIELHAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:KIMBERLY BOULDRY
Mailing Address - Street 1:6106 HUCKLEBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-4176
Mailing Address - Country:US
Mailing Address - Phone:407-668-5431
Mailing Address - Fax:
Practice Address - Street 1:1485 LEGENDS BLVD
Practice Address - Street 2:
Practice Address - City:CHAMPIONS GATE
Practice Address - State:FL
Practice Address - Zip Code:33896-8393
Practice Address - Country:US
Practice Address - Phone:407-390-6480
Practice Address - Fax:407-390-6483
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-10
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106227363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical