Provider Demographics
NPI:1790154169
Name:BASHAM, KIMBERLY JOY (APRN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOY
Last Name:BASHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 LAKE SUMTER LNDG
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-2699
Mailing Address - Country:US
Mailing Address - Phone:352-674-8905
Mailing Address - Fax:352-674-8919
Practice Address - Street 1:8877 SE 165TH MULBERRY LN
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5887
Practice Address - Country:US
Practice Address - Phone:352-674-1750
Practice Address - Fax:352-674-8950
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9430779363L00000X
IL209013223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily