Provider Demographics
NPI:1689630238
Name:FEWINS, KIMBERLY (CRNA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FEWINS
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 1:1974 LAGOON DR
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2107
Mailing Address - Country:US
Mailing Address - Phone:517-347-4996
Mailing Address - Fax:
Practice Address - Street 1:3565 S STATE RD
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-9416
Practice Address - Country:US
Practice Address - Phone:616-523-1498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704159168367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104594488Medicaid
MIN47230045Medicare ID - Type UnspecifiedLOC 99
MIN78650027Medicare ID - Type UnspecifiedLOC 01