Provider Demographics
NPI:1760600290
Name:KIMBLE, DEBORAH (LD CDE MSPH CPT)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:LD CDE MSPH CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4851 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-7577
Mailing Address - Country:US
Mailing Address - Phone:407-973-0037
Mailing Address - Fax:407-957-1186
Practice Address - Street 1:4851 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-7577
Practice Address - Country:US
Practice Address - Phone:407-973-0037
Practice Address - Fax:407-957-1186
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND1612133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7736Medicare UPIN