MEDICARE: LISA YONG KIMMERLE CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	RN178243	GA
2	367500000X	Certified Registered Nurse Anesthetist	230428	NC

General Provider Information

NPI Number	:	1124066881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA YONG KIMMERLE CRNA

Provider Business Mailing Address
First Line	:	616 WINTER WHEAT CT
Second Line	:
City	:	WEDDINGTON
State	:	NC
Zip	:	28104-6136
Country	:	US
Telephone Number	:	704-774-9225
Fax Number	:

Provider Business Practice Location Address
First Line	:	14215 BALLANTYNE CORPORATE PL STE 210
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-3873
Country	:	US
Telephone Number	:	704-316-2650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	05/16/2022

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