Basic Information
| Provider Information | |||||||||
| NPI: | 1457672628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDIS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 217 HARRISBURG AVE | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176032964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175448300 | ||||||||
| FaxNumber: | 7175448265 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 HARRISBURG AVE | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176032964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175448300 | ||||||||
| FaxNumber: | 7175448265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2010 | ||||||||
| LastUpdateDate: | 05/19/2016 | ||||||||
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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 | 163W00000X | SP010524 | PA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | SP010524 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | ML2179415 | 01 | PA | DEA | OTHER |