=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790736957
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTEN M GRINE DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2006
-----------------------------------------------------
Last Update Date | 03/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 476 ROLLING RIDGE DR STE 101
-----------------------------------------------------
City | STATE COLLEGE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16801-7639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-689-4980
-----------------------------------------------------
Fax | 814-689-4990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 858 MC A410
-----------------------------------------------------
City | HERSHEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17033-0858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-243-1455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS013057
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------