Provider Demographics
NPI:1831482165
Name:GANNON, KIMBERLY PARKER (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:PARKER
Last Name:GANNON
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HYGEIA DR
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:SUITE 1070
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-733-5982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT199438207R00000X, 390200000X, 2084N0400X
DEC1-00115142084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program