Provider Demographics
NPI:1134162944
Name:RICKETSON, KIM T (CRNA)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:T
Last Name:RICKETSON
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 1:3825 LAMONT ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-4049
Mailing Address - Country:US
Mailing Address - Phone:804-262-6141
Mailing Address - Fax:
Practice Address - Street 1:3825 LAMONT ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-4049
Practice Address - Country:US
Practice Address - Phone:804-262-6141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024094136367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered