Healthcare Provider Details

I. General information

NPI: 1134685183
Provider Name (Legal Business Name): KIMBERLY ANNA GROSSNICKLE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46B THOMAS JOHNSON DR STE 200
FREDERICK MD
21702-4501
US

IV. Provider business mailing address

11720 BELTSVILLE DR STE 300
BELTSVILLE MD
20705-3119
US

V. Phone/Fax

Practice location:
  • Phone: 301-695-6777
  • Fax:
Mailing address:
  • Phone: 240-223-1799
  • Fax: 832-348-5791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR200925
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR200925
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: