Healthcare Provider Details

I. General information

NPI: 1619354487
Provider Name (Legal Business Name): KIM REISER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 CENTRAL AVE
DOVER NH
03820-2526
US

IV. Provider business mailing address

19 BRIDGE STREET UNIT 2
KITTERY ME
03904
US

V. Phone/Fax

Practice location:
  • Phone: 603-609-6819
  • Fax:
Mailing address:
  • Phone: 617-504-2667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number184236
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number087891-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: