Provider Demographics
NPI:1538766837
Name:MARTYN, KIMBERLY ANN (MSN, FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:MARTYN
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:RAFFAELE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:168 W BALTIMORE PIKE
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063
Mailing Address - Country:US
Mailing Address - Phone:570-778-3295
Mailing Address - Fax:
Practice Address - Street 1:168 W BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063
Practice Address - Country:US
Practice Address - Phone:570-778-3295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP022745363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner