Provider Demographics
NPI:1871867762
Name:WHALEY, KIMYATA MARIE (MA)
Entity Type:Individual
Prefix:MS
First Name:KIMYATA
Middle Name:MARIE
Last Name:WHALEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11735 CHERRY BARK DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-7677
Mailing Address - Country:US
Mailing Address - Phone:904-358-1211
Mailing Address - Fax:904-854-6553
Practice Address - Street 1:623 BEECHWOOD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-6236
Practice Address - Country:US
Practice Address - Phone:904-358-1211
Practice Address - Fax:904-854-6553
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator