Healthcare Provider Details

I. General information

NPI: 1194058024
Provider Name (Legal Business Name): KIMBERLY TOWNES SODEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRAIL
RALEIGH NC
27607
US

IV. Provider business mailing address

1107 FRONT GATE DR
WAKE FOREST NC
27587-3856
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-3034
  • Fax:
Mailing address:
  • Phone: 919-417-8759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number166766
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number083031
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: