Provider Demographics
NPI:1851919526
Name:PANNI, KYRA
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:PANNI
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 1:4090 HODGES BLVD APT 2608
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-4223
Mailing Address - Country:US
Mailing Address - Phone:410-726-8247
Mailing Address - Fax:
Practice Address - Street 1:3857 HARTWOOD LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1486
Practice Address - Country:US
Practice Address - Phone:419-726-8247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113681363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical