Provider Demographics
NPI:1952352239
Name:MANSELL, KIMBERLY GRANT (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GRANT
Last Name:MANSELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 510209
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33951-0209
Mailing Address - Country:US
Mailing Address - Phone:941-347-8317
Mailing Address - Fax:
Practice Address - Street 1:2500 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5000
Practice Address - Country:US
Practice Address - Phone:941-625-4155
Practice Address - Fax:941-625-4155
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1350-06207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPENDINGMedicaid
NMPENDINGMedicare ID - Type Unspecified
NMF81171Medicare UPIN