Basic Information
Provider Information
NPI: 1003142373
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VERBARG
FirstName: KIMBERLY
MiddleName: A
NamePrefix:  
NameSuffix:  
Credential: L.M.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 215 LITHIA PINECREST RD
Address2:  
City: BRANDON
State: FL
PostalCode: 335115307
CountryCode: US
TelephoneNumber: 8136858404
FaxNumber: 8132980620
Practice Location
Address1: 215 LITHIA PINECREST RD
Address2:  
City: BRANDON
State: FL
PostalCode: 33511
CountryCode: US
TelephoneNumber: 8136858404
FaxNumber: 8132980620
Other Information
ProviderEnumerationDate: 10/21/2009
LastUpdateDate: 06/20/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
176B00000XMW 230FLY Other Service ProvidersMidwife 

No ID Information.


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