Provider Demographics
NPI:1184053498
Name:KLECKNER, KIMBERLEY (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLEY
Middle Name:
Last Name:KLECKNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 MIRABAY BLVD
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-3412
Mailing Address - Country:US
Mailing Address - Phone:973-412-5610
Mailing Address - Fax:
Practice Address - Street 1:14470 HARLEE RD
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-9600
Practice Address - Country:US
Practice Address - Phone:941-747-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN17489207Q00000X
WAMD60528246207Q00000X
FLME121675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01597812OtherRR PTAN WVH
WA1184053498Medicaid
WAG8941553, G8941554Medicare PIN