1194911412 NPI number — MISS KIMBERLY WIEST CRNA

Table of content: MISS KIMBERLY WIEST CRNA (NPI 1194911412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194911412 NPI number — MISS KIMBERLY WIEST CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIEST
Provider First Name:
KIMBERLY
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FENOLI
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194911412
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40908
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28309-0908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-615-5132
Provider Business Mailing Address Fax Number:
910-321-6236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1638 OWEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304-3424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-615-5132
Provider Business Practice Location Address Fax Number:
910-321-6236
Provider Enumeration Date:
09/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  115495 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1194911412 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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