Provider Demographics
NPI:1790352607
Name:KIM-HUMMEL, SU
Entity Type:Individual
Prefix:
First Name:SU
Middle Name:
Last Name:KIM-HUMMEL
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 1:11661 PLANTATION PRESERVE CIR S
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-8372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11661 PLANTATION PRESERVE CIR S
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-8372
Practice Address - Country:US
Practice Address - Phone:239-288-1760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9362737163W00000X
FLAPRN11013909363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse