Provider Demographics
NPI:1518988120
Name:KIMBERLY, SALLY L (CNM)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:L
Last Name:KIMBERLY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-392-4491
Mailing Address - Fax:352-392-9912
Practice Address - Street 1:1600 SW ARCHER ROAD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0371
Practice Address - Country:US
Practice Address - Phone:352-392-4491
Practice Address - Fax:352-392-9912
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1606692367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL033630100Medicaid
FL033630100Medicaid
Y7433XMedicare PIN