Basic Information
| Provider Information | |||||||||
| NPI: | 1831262104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAHNSEN | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 370 TOW HILL RD | ||||||||
| Address2: | |||||||||
| City: | PORT MATILDA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168707923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8146927398 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 HOWARD AVE STE B | ||||||||
| Address2: | |||||||||
| City: | ALTOONA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166014810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8149421903 | ||||||||
| FaxNumber: | 8145051100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN543741L | PA | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1015945850001 | 05 | PA | MEDICAID |