Provider Demographics
NPI:1053443796
Name:CHANNELS, KIMBERLY ANNE (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:CHANNELS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15320 AMBERLY DR
Mailing Address - Street 2:STE A
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-1647
Mailing Address - Country:US
Mailing Address - Phone:813-977-2090
Mailing Address - Fax:813-977-9107
Practice Address - Street 1:15320 AMBERLY DR
Practice Address - Street 2:SUITE, A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-1647
Practice Address - Country:US
Practice Address - Phone:813-977-0733
Practice Address - Fax:813-971-2230
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA 3270363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA LICENSE PA 3270OtherPHYSICIAN ASSISTANT ID