Provider Demographics
NPI:1114023967
Name:RUPP-MONTPETIT, KIMBERLY DIANE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DIANE
Last Name:RUPP-MONTPETIT
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 1:410 LAKE AVE S
Mailing Address - Street 2:
Mailing Address - City:SPICER
Mailing Address - State:MN
Mailing Address - Zip Code:56288-8614
Mailing Address - Country:US
Mailing Address - Phone:320-796-0434
Mailing Address - Fax:
Practice Address - Street 1:301 BECKER AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3302
Practice Address - Country:US
Practice Address - Phone:320-231-4120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 116376-8367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered