Provider Demographics
NPI:1811904915
Name:GANNOE, KRISTIN LEIGH (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:LEIGH
Last Name:GANNOE
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 1:28 RAHLING CIR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-9187
Mailing Address - Country:US
Mailing Address - Phone:501-448-0060
Mailing Address - Fax:501-448-0066
Practice Address - Street 1:28 RAHLING CIR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-9187
Practice Address - Country:US
Practice Address - Phone:501-448-0060
Practice Address - Fax:501-448-0066
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE36942084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150663001Medicaid
AR5M706Medicare ID - Type Unspecified
AR150663001Medicaid