Provider Demographics
NPI:1912967159
Name:DYSON, KIM A (CNM)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:DYSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 36TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4862
Mailing Address - Country:US
Mailing Address - Phone:772-567-4311
Mailing Address - Fax:
Practice Address - Street 1:787 37TH ST
Practice Address - Street 2:SUITE E-170
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-7305
Practice Address - Country:US
Practice Address - Phone:772-770-6116
Practice Address - Fax:772-564-6120
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1498862367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0380OtherBLUE CROSS
FLY0380OtherBLUE CROSS
FLY0380ZMedicare ID - Type Unspecified
FLY0380YMedicare PIN