Provider Demographics
NPI:1730727314
Name:MACKAY, KIMBERLY DIANE (NNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:MACKAY
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3508
Mailing Address - Fax:904-244-4301
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-3508
Practice Address - Fax:904-244-4301
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-14
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX683428163W00000X
FLAPRN11030321363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical CareGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN11030321OtherFLORIDA APRN LIC