Provider Demographics
NPI:1811386105
Name:KIDD, LAUREN AMBER (CRNA)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:AMBER
Last Name:KIDD
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 1:109 MEADOW VIEW RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1661
Mailing Address - Country:US
Mailing Address - Phone:423-844-4182
Mailing Address - Fax:423-764-2457
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19553367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I430885Medicare PIN