Provider Demographics
NPI:1639318967
Name:TANNER, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12276 SAN JOSE BLVD
Mailing Address - Street 2:STE 507
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8628
Mailing Address - Country:US
Mailing Address - Phone:904-288-8910
Mailing Address - Fax:904-288-8912
Practice Address - Street 1:12276 SAN JOSE BLVD
Practice Address - Street 2:STE 507
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8628
Practice Address - Country:US
Practice Address - Phone:904-288-8910
Practice Address - Fax:904-288-8912
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist