Basic Information
| Provider Information | |||||||||
| NPI: | 1912967159 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYSON | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 36TH ST | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329604862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725674311 | ||||||||
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| Practice Location | |||||||||
| Address1: | 787 37TH ST | ||||||||
| Address2: | SUITE E-170 | ||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329607305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7727706116 | ||||||||
| FaxNumber: | 7725646120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 02/15/2008 | ||||||||
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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 | 367A00000X | ARNP 1498862 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | Y0380 | 01 | FL | BLUE CROSS | OTHER |