Provider Demographics
NPI:1679566699
Name:COMSTOCK, KIMBERLY (CRNA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:COMSTOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BACA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:610 W GERMANTOWN PIKE SUITE 150
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 W GERMANTOWN PIKE UNIT 150
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1050
Practice Address - Country:US
Practice Address - Phone:610-525-4966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNR73787367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ006099Medicare ID - Type Unspecified