Healthcare Provider Details

I. General information

NPI: 1881001162
Provider Name (Legal Business Name): KIMBERLY W STACKPOLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 WESTHALL LN STE 4
MAITLAND FL
32751-7102
US

IV. Provider business mailing address

311 N CLYDE MORRIS BLVD SUITE 320
DAYTONA BEACH FL
32114-2781
US

V. Phone/Fax

Practice location:
  • Phone: 407-200-2355
  • Fax: 407-200-4947
Mailing address:
  • Phone: 386-255-5331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9108139
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: