Provider Demographics
NPI:1831780014
Name:KIMBRO, PORSCHA SHANTELL (ARNP)
Entity type:Individual
Prefix:
First Name:PORSCHA
Middle Name:SHANTELL
Last Name:KIMBRO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 GALAXY ST
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-7216
Mailing Address - Country:US
Mailing Address - Phone:407-574-1776
Mailing Address - Fax:
Practice Address - Street 1:1043 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8360
Practice Address - Country:US
Practice Address - Phone:386-774-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007402363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner