Provider Demographics
NPI:1164128575
Name:EDOUARD, KEMBERLINE
Entity type:Individual
Prefix:
First Name:KEMBERLINE
Middle Name:
Last Name:EDOUARD
Suffix:
Gender:F
Credentials:
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3660
Mailing Address - Fax:239-343-4133
Practice Address - Street 1:708 DEL PRADO BLVD S STE 7
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2676
Practice Address - Country:US
Practice Address - Phone:239-343-3660
Practice Address - Fax:239-343-4133
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9120422363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL128334400Medicaid