Basic Information
| Provider Information | |||||||||
| NPI: | 1902168982 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PITTMAN | ||||||||
| FirstName: | KIMBERLI | ||||||||
| MiddleName: | VONKEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3493 SE JAKE CT APT 98 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349945057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7729852018 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15818 SW WARFIELD BLVD | ||||||||
| Address2: | |||||||||
| City: | INDIANTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349563513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725970411 | ||||||||
| FaxNumber: | 7725970412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2012 | ||||||||
| LastUpdateDate: | 06/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.