Healthcare Provider Details

I. General information

NPI: 1629151931
Provider Name (Legal Business Name): KENNETH MICHAEL PLUMLEY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5620 CHERRY ST
CALLAWAY FL
32404
US

IV. Provider business mailing address

PO BOX 1568
LYNN HAVEN FL
32444-1568
US

V. Phone/Fax

Practice location:
  • Phone: 800-215-7210
  • Fax: 850-215-7213
Mailing address:
  • Phone: 850-769-6612
  • Fax: 850-769-3533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0001942
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: