Provider Demographics
NPI:1003041617
Name:HARRIS, KIMBERLY DAWN (CRNA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPT 203401
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0002
Mailing Address - Country:US
Mailing Address - Phone:888-278-4126
Mailing Address - Fax:
Practice Address - Street 1:3990 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2018
Practice Address - Country:US
Practice Address - Phone:313-745-8521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704169677367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N24360430Medicare PIN