Healthcare Provider Details

I. General information

NPI: 1518455823
Provider Name (Legal Business Name): KIERSTEN JESSICA PANNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 CENTER DR
GAINESVILLE FL
32610-3006
US

IV. Provider business mailing address

802 BETH PAGE DR APT 911
AUGUSTA GA
30907-7404
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-5800
  • Fax:
Mailing address:
  • Phone: 678-517-8692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: