Provider Demographics
NPI:1518455823
Name:PANNELL, KIERSTEN JESSICA
Entity Type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:JESSICA
Last Name:PANNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 BETH PAGE DR APT 911
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-7404
Mailing Address - Country:US
Mailing Address - Phone:678-517-8692
Mailing Address - Fax:
Practice Address - Street 1:1395 CENTER DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3006
Practice Address - Country:US
Practice Address - Phone:352-273-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program