Healthcare Provider Details

I. General information

NPI: 1114023967
Provider Name (Legal Business Name): KIMBERLY DIANE RUPP-MONTPETIT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 BECKER AVE SW
WILLMAR MN
56201-3302
US

IV. Provider business mailing address

410 LAKE AVE S
SPICER MN
56288-8614
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-4120
  • Fax:
Mailing address:
  • Phone: 320-796-0434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 116376-8
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: