Provider Demographics
NPI:1588862098
Name:ELLIOTT, KIMBERLY ANN (DO)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:ELLIOTT
Suffix:
Gender:F
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 3266
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3266
Mailing Address - Country:US
Mailing Address - Phone:904-420-2644
Mailing Address - Fax:904-819-4906
Practice Address - Street 1:100 WHETSTONE PL STE 105
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5775
Practice Address - Country:US
Practice Address - Phone:904-824-3777
Practice Address - Fax:904-824-6050
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60151452207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807774300Medicaid