Healthcare Provider Details

I. General information

NPI: 1609935568
Provider Name (Legal Business Name): KIMBERLY JEAN BIBB CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6435 W JEFFERSON BLVD # 434
FORT WAYNE IN
46804-6203
US

IV. Provider business mailing address

PO BOX 843603
DALLAS TX
75284-0001
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-7875
  • Fax: 260-432-9812
Mailing address:
  • Phone: 972-233-1999
  • Fax: 972-233-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3005106
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1074359
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28292555A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: