Provider Demographics
NPI:1861164808
Name:MIEDEMA, KIMBERLY BLANCH (RRT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BLANCH
Last Name:MIEDEMA
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BLANCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RRT
Mailing Address - Street 1:275 SW BENJAMIN PL
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038-3003
Mailing Address - Country:US
Mailing Address - Phone:352-219-1890
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-219-1890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRT12144227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered