Healthcare Provider Details

I. General information

NPI: 1245222447
Provider Name (Legal Business Name): ROBERTA MARIE KILLEEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 US HIGHWAY 19
HOLIDAY FL
34691-3846
US

IV. Provider business mailing address

2520 US HIGHWAY 19
HOLIDAY FL
34691-3846
US

V. Phone/Fax

Practice location:
  • Phone: 727-934-6905
  • Fax: 727-934-4045
Mailing address:
  • Phone: 727-934-6905
  • Fax: 727-934-4045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberME58665
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: