Basic Information
| Provider Information | |||||||||
| NPI: | 1205257136 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOOSALES | ||||||||
| FirstName: | KIMBERLEY | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | C-AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100254 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522738610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3231 MCMULLEN BOOTH RD | ||||||||
| Address2: | |||||||||
| City: | SAFETY HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277256111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2013 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | AA211 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.