Provider Demographics
NPI:1598734675
Name:HICKEY, KIMBERLE J (CRNA)
Entity Type:Individual
Prefix:
First Name:KIMBERLE
Middle Name:J
Last Name:HICKEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIMBERLE
Other - Middle Name:A
Other - Last Name:JUREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 465686
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30042-5686
Mailing Address - Country:US
Mailing Address - Phone:770-237-1561
Mailing Address - Fax:770-237-1124
Practice Address - Street 1:201 HOSPITAL RD
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2408
Practice Address - Country:US
Practice Address - Phone:404-851-6500
Practice Address - Fax:770-237-1124
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN147449367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP28088Medicare UPIN