Provider Demographics
NPI:1568543379
Name:KIMMEL, CHERYL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:
Last Name:KIMMEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1256 ROBBIN DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-7426
Mailing Address - Country:US
Mailing Address - Phone:386-756-4497
Mailing Address - Fax:
Practice Address - Street 1:77 W GRANADA BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-6302
Practice Address - Country:US
Practice Address - Phone:386-677-0453
Practice Address - Fax:386-677-5494
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102863363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26863OtherBLUE CROSS BLUE SHIELD
FL26863OtherBLUE CROSS BLUE SHIELD