MEDICARE: KIERSTEN MARIE FANELL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9120745	FL
2	363AS0400X	Surgical Physician Assistant	PA9120745	FL

General Provider Information

NPI Number	:	1013894856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIERSTEN MARIE FANELL PA-C

Provider Business Mailing Address
First Line	:	200 SE HOSPITAL AVE # 2346
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34994-2346
Country	:	US
Telephone Number	:	661-858-3326
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 SE HOSPITAL AVE
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34994-2346
Country	:	US
Telephone Number	:	772-287-5200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2025
Last Update Date	:	01/11/2026

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