Provider Demographics
NPI:1932163482
Name:PICKETT, KIMBERLY (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PICKETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N PARSONS AVE
Mailing Address - Street 2:SUITE 108B
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-4538
Mailing Address - Country:US
Mailing Address - Phone:813-643-7225
Mailing Address - Fax:813-643-5280
Practice Address - Street 1:119 OAKFIELD DR
Practice Address - Street 2:NICU FLOOR
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5779
Practice Address - Country:US
Practice Address - Phone:813-571-5360
Practice Address - Fax:813-571-5242
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102843363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical