Healthcare Provider Details

I. General information

NPI: 1598734675
Provider Name (Legal Business Name): KIMBERLE J HICKEY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLE A JUREK

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HOSPITAL RD ANESTHESIA DEPARTMENT
CANTON GA
30114-2408
US

IV. Provider business mailing address

PO BOX 465686
LAWRENCEVILLE GA
30042-5686
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-6500
  • Fax: 770-237-1124
Mailing address:
  • Phone: 770-237-1561
  • Fax: 770-237-1124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN147449
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: