Basic Information
| Provider Information | |||||||||
| NPI: | 1720385438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUDZIL | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | MYERS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MYERS | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12470 TELECOM DR STE 300W | ||||||||
| Address2: | |||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336370904 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14547 BRUCE B DOWNS BLVD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336132709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139790440 | ||||||||
| FaxNumber: | 8133555054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2011 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9249012 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | P01024265 | 01 | FL | RR MEDICARE | OTHER | 003353100 | 05 | FL | MEDICAID |