Provider Demographics
NPI:1326773516
Name:MATTESON, KIMBERLY ROSE (CRNA, DNAP)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ROSE
Last Name:MATTESON
Suffix:
Gender:F
Credentials:CRNA, DNAP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ROSE
Other - Last Name:RAMEIKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1956 S COUNTY TRL
Mailing Address - Street 2:
Mailing Address - City:WEST KINGSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02892-1600
Mailing Address - Country:US
Mailing Address - Phone:401-477-0896
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-6779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN03227367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered