Healthcare Provider Details

I. General information

NPI: 1487708137
Provider Name (Legal Business Name): LOIS J KIMBERLEY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

1060 BONNIE BRAE ST NE
LELAND NC
28451-8528
US

V. Phone/Fax

Practice location:
  • Phone: 910-343-7000
  • Fax:
Mailing address:
  • Phone: 910-371-1823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number110419
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: