Provider Demographics
NPI:1720385438
Name:CUDZIL, KIMBERLY MYERS (ARNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MYERS
Last Name:CUDZIL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:E
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:12470 TELECOM DR STE 300W
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14547 BRUCE B DOWNS BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2709
Practice Address - Country:US
Practice Address - Phone:813-979-0440
Practice Address - Fax:813-355-5054
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9249012363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01024265OtherRR MEDICARE
FL003353100Medicaid
FLET795Z - TPAMedicare PIN
FLET795Y - PASCOMedicare PIN