Provider Demographics
NPI:1376918755
Name:RICHARDSON, KIMBERLY D (CRNA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DEMARIS
Other - Last Name:MAHAFFEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:601 SOUTH FLOYD STREET
Mailing Address - Street 2:CHFB #470
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-6314
Mailing Address - Country:US
Mailing Address - Phone:150-262-9288
Mailing Address - Fax:150-262-9287
Practice Address - Street 1:601 SOUTH FLOYD STREET
Practice Address - Street 2:CHFB #470
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-6314
Practice Address - Country:US
Practice Address - Phone:150-262-9288
Practice Address - Fax:150-262-9287
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010034367500000X
CA95000812367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered