Provider Demographics
NPI:1194911412
Name:WIEST, KIMBERLY (CRNA)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:
Last Name:WIEST
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:FENOLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 40908
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28309-0908
Mailing Address - Country:US
Mailing Address - Phone:910-615-5132
Mailing Address - Fax:910-321-6236
Practice Address - Street 1:1638 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3424
Practice Address - Country:US
Practice Address - Phone:910-615-5132
Practice Address - Fax:910-321-6236
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC115495367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1194911412Medicaid
NCPENDINGMedicare Oscar/Certification