Healthcare Provider Details

I. General information

NPI: 1003396672
Provider Name (Legal Business Name): KIMBERLY MCCONNELL CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 E 23RD ST
PANAMA CITY FL
32405-4501
US

IV. Provider business mailing address

103 E 23RD ST
PANAMA CITY FL
32405-4501
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-0338
  • Fax: 850-640-2195
Mailing address:
  • Phone: 850-769-0338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberAPRN11004896
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: