Provider Demographics
NPI:1124066881
Name:KIMMERLE, LISA YONG (CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:YONG
Last Name:KIMMERLE
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 1:616 WINTER WHEAT CT
Mailing Address - Street 2:
Mailing Address - City:WEDDINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28104-6136
Mailing Address - Country:US
Mailing Address - Phone:704-774-9225
Mailing Address - Fax:
Practice Address - Street 1:14215 BALLANTYNE CORPORATE PL STE 210
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3873
Practice Address - Country:US
Practice Address - Phone:704-316-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN178243367500000X
NC230428367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered