Provider Demographics
NPI:1639183635
Name:STAUFFER, KIMBERLY A (MS, CRNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:STAUFFER
Suffix:
Gender:F
Credentials:MS, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 MEDICAL PARKWAY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3088
Mailing Address - Country:US
Mailing Address - Phone:410-573-2530
Mailing Address - Fax:410-573-2536
Practice Address - Street 1:2003 MEDICAL PARKWAY
Practice Address - Street 2:SUITE 400
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3088
Practice Address - Country:US
Practice Address - Phone:410-573-2530
Practice Address - Fax:410-573-2536
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR083215363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD003742A13Medicare ID - Type UnspecifiedMEDICARE# PRINCE GEORGE C
S58734Medicare UPIN
MD7734Medicare ID - Type UnspecifiedMEDICARE# ANNE ARUNDEL CO