Provider Demographics
NPI:1912310509
Name:HOGAN, KIMBERLY (ARNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HOGAN
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:PO BOX 62707
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-2707
Mailing Address - Country:US
Mailing Address - Phone:239-931-3440
Mailing Address - Fax:
Practice Address - Street 1:13813 METRO PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4343
Practice Address - Country:US
Practice Address - Phone:239-936-1343
Practice Address - Fax:239-936-8507
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3132002363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016227400Medicaid
FLY0N4VOtherFLORIDA BLUE
FL016227400Medicaid