Provider Demographics
NPI:1346582756
Name:MANCL, KIMBERLY ANN (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:MANCL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:KOLSTEDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14071 METROPOLIS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4330
Mailing Address - Country:US
Mailing Address - Phone:239-694-7546
Mailing Address - Fax:239-694-1571
Practice Address - Street 1:14071 METROPOLIS AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4330
Practice Address - Country:US
Practice Address - Phone:239-694-7546
Practice Address - Fax:239-694-1571
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-24
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME132443207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology