=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275294548
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY JEANETTE MIELKE CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2022
-----------------------------------------------------
Last Update Date | 01/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 LAWN AVE
-----------------------------------------------------
City | SELLERSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18960-1548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 E MAIN ST
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16928-9747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-439-1937
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | SP024749
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------