Basic Information
| Provider Information | |||||||||
| NPI: | 1083660997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIGNOR-MCCLELLAN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MSN, CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 CHERRY ST | ||||||||
| Address2: | SUITE 11511 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152557822 | ||||||||
| FaxNumber: | 2152557825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1427 VINE ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157622533 | ||||||||
| FaxNumber: | 2157622531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 08/31/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP008989 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | SP008989 | 01 | PA | CRNP LICENSE NUMBER | OTHER | 100939QHR | 01 | PA | MEDICARE NUMBER 100939QHR | OTHER |