Provider Demographics
NPI:1033575907
Name:WALLEN, KIMBERLY GLENDORIA (CRNA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GLENDORIA
Last Name:WALLEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:GLENDORIA
Other - Last Name:LEIGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3334 MONIDA ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-8648
Mailing Address - Country:US
Mailing Address - Phone:804-647-1635
Mailing Address - Fax:
Practice Address - Street 1:3334 MONIDA ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-8648
Practice Address - Country:US
Practice Address - Phone:804-647-1635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT146248367500000X
KS108532367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered