Provider Demographics
NPI:1265777544
Name:KANNENBERG, KIMBERLY (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KANNENBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 SOUTH CONGRESS AVENUE
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445
Mailing Address - Country:US
Mailing Address - Phone:561-330-9363
Mailing Address - Fax:
Practice Address - Street 1:1425 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-6384
Practice Address - Country:US
Practice Address - Phone:561-330-9363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9106163363A00000X
TX00269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant