Healthcare Provider Details

I. General information

NPI: 1316225642
Provider Name (Legal Business Name): KIMBERLY Y DANIEL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY Y LUSK RN

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3257 GLENVIEW CIR SW
ATLANTA GA
30331-2405
US

IV. Provider business mailing address

3257 GLENVIEW CIR SW
ATLANTA GA
30331-2405
US

V. Phone/Fax

Practice location:
  • Phone: 404-808-5203
  • Fax:
Mailing address:
  • Phone: 404-808-5203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209034236
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN168271
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: