Provider Demographics
NPI:1326125816
Name:BEATTY, KIMBERLY ANN (CRNA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:BEATTY
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 1:119 KING ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5732
Mailing Address - Country:US
Mailing Address - Phone:301-665-1717
Mailing Address - Fax:301-665-1810
Practice Address - Street 1:11116 MEDICAL CAMPUS RD
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6710
Practice Address - Country:US
Practice Address - Phone:301-665-1717
Practice Address - Fax:302-709-2402
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2962367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0078076700002Medicaid
MDR185390OtherMD LICENSE
PA050514OtherMEDICARE GROUP #
PARN534747OtherPA LICENSE
PA064238P1KMedicare PIN
PAP72181Medicare UPIN