Basic Information
| Provider Information | |||||||||
| NPI: | 1134869753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CITTADINO | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CITTADINO | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1601 NE BRAILLE PL | ||||||||
| Address2: | |||||||||
| City: | JENSEN BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349575345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723200770 | ||||||||
| FaxNumber: | 7724443589 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 NE BRAILLE PL | ||||||||
| Address2: | |||||||||
| City: | JENSEN BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349575345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723200770 | ||||||||
| FaxNumber: | 7724443589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2022 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | FL | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 59-1051699 | 05 | FL | MEDICAID |