Provider Demographics
NPI:1104858299
Name:ALEXANDER, KIMBERLY JO (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JO
Last Name:ALEXANDER
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 1:220 FERNCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-7211
Mailing Address - Country:US
Mailing Address - Phone:704-636-1420
Mailing Address - Fax:
Practice Address - Street 1:612 MOCKSVILLE AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2732
Practice Address - Country:US
Practice Address - Phone:704-210-5661
Practice Address - Fax:704-210-5660
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC43119367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8050434Medicaid
NC2627771Medicare ID - Type Unspecified