Provider Demographics
NPI:1588389027
Name:SHAFFER, KIMBERLY GRACE (FNP-C, CRNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GRACE
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:FNP-C, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18436-7708
Mailing Address - Country:US
Mailing Address - Phone:570-561-4472
Mailing Address - Fax:
Practice Address - Street 1:820 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-1639
Practice Address - Country:US
Practice Address - Phone:570-561-4472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAF08220620363L00000X
PASP026314363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner