=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720792708
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY REILLY CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2023
-----------------------------------------------------
Last Update Date | 01/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 YORK RD STE 300
-----------------------------------------------------
City | LUTHERVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093-6019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-747-6669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 BURROWS RD APT 306
-----------------------------------------------------
City | RED LION
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17356-9295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-747-6669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | R216667
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------