Provider Demographics
NPI:1245535749
Name:FERN, KIMBERLY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:FERN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 JENNIFER RD STE 240
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7995
Mailing Address - Country:US
Mailing Address - Phone:410-571-9000
Mailing Address - Fax:410-266-1507
Practice Address - Street 1:170 JENNIFER RD STE 240
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7995
Practice Address - Country:US
Practice Address - Phone:410-571-9000
Practice Address - Fax:410-266-1507
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04388363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant