Healthcare Provider Details

I. General information

NPI: 1194637652
Provider Name (Legal Business Name): KIMORA MCCONNELL MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 FOREST RD
HAVANA FL
32333-6505
US

IV. Provider business mailing address

90 FOREST RD
HAVANA FL
32333-6505
US

V. Phone/Fax

Practice location:
  • Phone: 850-510-6669
  • Fax:
Mailing address:
  • Phone: 850-510-6669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: