Basic Information
| Provider Information | |||||||||
| NPI: | 1891070330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | MELISSA | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218688364 | ||||||||
| FaxNumber: | 3219517408 | ||||||||
| Practice Location | |||||||||
| Address1: | 699 W COCOA BEACH CSWY | ||||||||
| Address2: | SUITE 603 | ||||||||
| City: | COCOA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329313577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218688364 | ||||||||
| FaxNumber: | 3218688372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2011 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9334301 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LX0001X | APRN9334301 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 004475500 | 05 | FL | MEDICAID | FR816Y | 01 | FL | MEDICARE | OTHER |