Basic Information
| Provider Information | |||||||||
| NPI: | 1861967564 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLLIS | ||||||||
| FirstName: | KIMBERLEY | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394241500 | ||||||||
| FaxNumber: | 2394241423 | ||||||||
| Practice Location | |||||||||
| Address1: | 8380 RIVERWALK PARK BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339198758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393439960 | ||||||||
| FaxNumber: | 2393439977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2018 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN281463 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN11013778 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 110958000 | 05 | FL | MEDICAID |