Provider Demographics
NPI:1134685183
Name:GROSSNICKLE, KIMBERLY ANNA (CRNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNA
Last Name:GROSSNICKLE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11720 BELTSVILLE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3119
Mailing Address - Country:US
Mailing Address - Phone:240-223-1799
Mailing Address - Fax:832-348-5791
Practice Address - Street 1:46B THOMAS JOHNSON DR STE 200
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4501
Practice Address - Country:US
Practice Address - Phone:301-695-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR200925163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse