MEDICARE: KIMBERLY GLENDORIA WALLEN CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	1081405	ID
2	367500000X	Certified Registered Nurse Anesthetist	108532	KS
3	367500000X	Certified Registered Nurse Anesthetist	2081405	ID
4	367500000X	Certified Registered Nurse Anesthetist	146248	MT

General Provider Information

NPI Number	:	1033575907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY GLENDORIA WALLEN CRNA

Provider Business Mailing Address
First Line	:	3334 MONIDA ST
Second Line	:
City	:	BOZEMAN
State	:	MT
Zip	:	59718-8648
Country	:	US
Telephone Number	:	804-647-1635
Fax Number	:

Provider Business Practice Location Address
First Line	:	3334 MONIDA ST
Second Line	:
City	:	BOZEMAN
State	:	MT
Zip	:	59718-8648
Country	:	US
Telephone Number	:	804-647-1635
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2016
Last Update Date	:	05/14/2026

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