Provider Demographics
NPI:1275294548
Name:MIELKE, KIMBERLY JEANETTE (CRNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEANETTE
Last Name:MIELKE
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 1:306 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16928-9747
Mailing Address - Country:US
Mailing Address - Phone:570-439-1937
Mailing Address - Fax:
Practice Address - Street 1:700 LAWN AVE
Practice Address - Street 2:
Practice Address - City:SELLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18960-1548
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP024749363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty