Provider Demographics
NPI:1659792018
Name:LENZ, KIM (CRNA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:LENZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:LENZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:203 S SANGAMON ST
Mailing Address - Street 2:APT 102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3030
Mailing Address - Country:US
Mailing Address - Phone:314-623-2316
Mailing Address - Fax:
Practice Address - Street 1:520 S MAPLE AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1022
Practice Address - Country:US
Practice Address - Phone:708-383-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011149041354844367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered