Provider Demographics
NPI:1881001162
Name:STACKPOLE, KIMBERLY W
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:W
Last Name:STACKPOLE
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 1:311 N CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2781
Mailing Address - Country:US
Mailing Address - Phone:386-255-5331
Mailing Address - Fax:
Practice Address - Street 1:311 N CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2781
Practice Address - Country:US
Practice Address - Phone:386-255-5331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical