Provider Demographics
NPI:1962795039
Name:RIENECKE, KIMBERLY (PA-C)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:RIENECKE
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 1:11701 LIVINGSTON RD STE 105
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5126
Mailing Address - Country:US
Mailing Address - Phone:301-292-7440
Mailing Address - Fax:301-292-3278
Practice Address - Street 1:11701 LIVINGSTON RD STE 105
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5126
Practice Address - Country:US
Practice Address - Phone:301-292-7440
Practice Address - Fax:301-292-3278
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004447363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical