Provider Demographics
NPI:1508013111
Name:NISSEN, KIMBERLY LYNN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:NISSEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ALEXIS DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-7718
Mailing Address - Country:US
Mailing Address - Phone:570-389-1503
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:PHARMACY 42-01
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-9800
Practice Address - Country:US
Practice Address - Phone:570-271-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP041116L1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy