Provider Demographics
NPI:1609935568
Name:BIBB, KIMBERLY JEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEAN
Last Name:BIBB
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0329
Mailing Address - Fax:502-588-0328
Practice Address - Street 1:530 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1675
Practice Address - Country:US
Practice Address - Phone:502-852-5851
Practice Address - Fax:502-852-3762
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1074359163W00000X
KY3005106367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY200873910Medicaid
KY7100021950Medicaid
IN200873910Medicaid
KY0516864Medicare Oscar/Certification
KY0516864Medicare PIN
KY7100021950Medicaid