Provider Demographics
NPI:1467689174
Name:PRINCE, KIERSTEN LEA (DO)
Entity Type:Individual
Prefix:DR
First Name:KIERSTEN
Middle Name:LEA
Last Name:PRINCE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:45465 FIFTH AVE
Practice Address - Street 2:
Practice Address - City:CALLAHAN
Practice Address - State:FL
Practice Address - Zip Code:32011-3901
Practice Address - Country:US
Practice Address - Phone:904-879-4544
Practice Address - Fax:904-879-4411
Is Sole Proprietor?:No
Enumeration Date:2009-06-20
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS11823207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01201601OtherRAILROAD MEDICARE
FLGO807ZMedicare PIN