Basic Information
| Provider Information | |||||||||
| NPI: | 1114455623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYDEL | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 871 CAMP FRANCIS JOHNSON RD | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320655832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046252415 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12276 SAN JOSE BLVD STE 508 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322238618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048863228 | ||||||||
| FaxNumber: | 9048863297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2017 | ||||||||
| LastUpdateDate: | 05/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.