Provider Demographics
NPI:1265757843
Name:OLIVER, KIMBERLY K (CRNA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
Last Name:OLIVER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:K
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 2759
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-2759
Mailing Address - Country:US
Mailing Address - Phone:920-830-5900
Mailing Address - Fax:
Practice Address - Street 1:1405 MILL ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2155
Practice Address - Country:US
Practice Address - Phone:920-531-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0191367500000X
WI6607-33367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNP00839047OtherRAILROAD MEDICARE
IAENROLLEDMedicaid
MNENROLLEDMedicaid