Healthcare Provider Details

I. General information

NPI: 1548439623
Provider Name (Legal Business Name): KIMBERLY JO DUTTLINGER RN, CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY JO BAYER R.N., CRNA

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 WEST ST
PERU IL
61354
US

IV. Provider business mailing address

925 WEST ST
PERU IL
61354-2757
US

V. Phone/Fax

Practice location:
  • Phone: 815-223-3300
  • Fax: 815-224-6763
Mailing address:
  • Phone: 815-223-3300
  • Fax: 815-224-6763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209006987
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: