Healthcare Provider Details

I. General information

NPI: 1912140831
Provider Name (Legal Business Name): STEPHANIE MARIE KIRKCONNELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4627 NW 53RD AVE
GAINESVILLE FL
32653-4857
US

IV. Provider business mailing address

PO BOX 358657
GAINESVILLE FL
32635-8657
US

V. Phone/Fax

Practice location:
  • Phone: 352-335-8888
  • Fax: 352-335-9427
Mailing address:
  • Phone: 352-335-8888
  • Fax: 352-335-9427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME112678
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: