Provider Demographics
NPI:1083620264
Name:KIMBERLY, JENNY BETH (CRNA)
Entity Type:Individual
Prefix:MS
First Name:JENNY
Middle Name:BETH
Last Name:KIMBERLY
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 1:8401 N RUSHVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46115-9771
Mailing Address - Country:US
Mailing Address - Phone:847-612-2199
Mailing Address - Fax:
Practice Address - Street 1:8401 N RUSHVILLE RD
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:IN
Practice Address - Zip Code:46115-9771
Practice Address - Country:US
Practice Address - Phone:847-612-2199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL309-002631367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK11065Medicare UPIN