Healthcare Provider Details

I. General information

NPI: 1013302660
Provider Name (Legal Business Name): KRIS-ANN SHANIQUE HUMPHREY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRIS-ANN SHANIQUE ROBERTSON

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 CONCOURSE PKWY S STE 200
MAITLAND FL
32751-6114
US

IV. Provider business mailing address

1800 DR MARTIN LUTHER KING JR ST N
ST PETERSBURG FL
33704-4222
US

V. Phone/Fax

Practice location:
  • Phone: 407-767-6411
  • Fax:
Mailing address:
  • Phone: 727-865-4288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number146759
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number146759
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: