Provider Demographics
NPI:1972977973
Name:BLUM, KIMBERLY (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BLUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 SE TIFFANY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7564
Mailing Address - Country:US
Mailing Address - Phone:772-223-4978
Mailing Address - Fax:772-398-1815
Practice Address - Street 1:1651 SE TIFFANY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7564
Practice Address - Country:US
Practice Address - Phone:772-223-4978
Practice Address - Fax:772-398-1815
Is Sole Proprietor?:No
Enumeration Date:2015-11-14
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9109154363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant