Provider Demographics
NPI:1679137392
Name:MCCANN, KRISTIE ANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTIE
Middle Name:ANN
Last Name:MCCANN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KRISTIE
Other - Middle Name:ANN
Other - Last Name:SCHIMMING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:136 S HOUSTON LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-6300
Mailing Address - Country:US
Mailing Address - Phone:478-953-1020
Mailing Address - Fax:
Practice Address - Street 1:136 S HOUSTON LAKE RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-6300
Practice Address - Country:US
Practice Address - Phone:478-953-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA9868207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty