Basic Information
| Provider Information | |||||||||
| NPI: | 1699906560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178516110 | ||||||||
| FaxNumber: | 7177411076 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 PINE GROVE CMNS | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178516110 | ||||||||
| FaxNumber: | 7177411076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2009 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | TP002141C | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1586612 | 01 | PA | GATEWAY-WMG | OTHER | 2132382 | 01 | PA | HIGHMARK FREEDOM BLUE | OTHER | 956320 | 01 | PA | CAREFIRST MD BCBS | OTHER |