Basic Information
| Provider Information | |||||||||
| NPI: | 1053443796 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANNELS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15320 AMBERLY DR | ||||||||
| Address2: | STE A | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336471647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139772090 | ||||||||
| FaxNumber: | 8139779107 | ||||||||
| Practice Location | |||||||||
| Address1: | 15320 AMBERLY DR | ||||||||
| Address2: | SUITE, A | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336471647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139770733 | ||||||||
| FaxNumber: | 8139712230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 11/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA 3270 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA LICENSE PA 3270 | 01 | FL | PHYSICIAN ASSISTANT ID | OTHER |