=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689630238
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY FEWINS CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2006
-----------------------------------------------------
Last Update Date | 11/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3565 S STATE RD
-----------------------------------------------------
City | IONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48846-9416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-523-1498
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1974 LAGOON DR
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864-2107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-347-4996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 4704159168
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------