Provider Demographics
NPI:1871268581
Name:JIMENEZ, WILMARIE IVETTE
Entity Type:Individual
Prefix:
First Name:WILMARIE
Middle Name:IVETTE
Last Name:JIMENEZ
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 1:505 W OAK ST STE 101
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4986
Mailing Address - Country:US
Mailing Address - Phone:407-847-7344
Mailing Address - Fax:407-483-0206
Practice Address - Street 1:505 W OAK ST STE 101
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4986
Practice Address - Country:US
Practice Address - Phone:407-847-7344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-13
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16342235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty