Provider Demographics
NPI:1124093828
Name:PETRAGNANI, KIMBERLY MARIE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:PETRAGNANI
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:M
Other - Last Name:PETRAGNANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 40767
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-0767
Mailing Address - Country:US
Mailing Address - Phone:904-376-3707
Mailing Address - Fax:904-391-5001
Practice Address - Street 1:6930 BONNEVAL RD STE 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6084
Practice Address - Country:US
Practice Address - Phone:904-854-6899
Practice Address - Fax:904-338-0533
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9191172363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP70841Medicare UPIN