Healthcare Provider Details

I. General information

NPI: 1184950925
Provider Name (Legal Business Name): KIMBERLY MARIE WADE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ATWELL RD
COOPERSTOWN NY
13326-1301
US

IV. Provider business mailing address

1 ATWELL RD
COOPERSTOWN NY
13326-1301
US

V. Phone/Fax

Practice location:
  • Phone: 607-547-3153
  • Fax:
Mailing address:
  • Phone: 607-547-3153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number623182
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: