Provider Demographics
NPI:1215076187
Name:KIM, ELIZABETH S (CRNA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:S
Last Name:KIM
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 1:4048 EVANS AVE
Mailing Address - Street 2:STE 303
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9322
Mailing Address - Country:US
Mailing Address - Phone:239-332-5344
Mailing Address - Fax:239-332-7246
Practice Address - Street 1:4048 EVANS AVE
Practice Address - Street 2:STE 303
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9322
Practice Address - Country:US
Practice Address - Phone:239-332-5344
Practice Address - Fax:239-332-7246
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175572367500000X
FL9211851367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG4220OtherBSFL
FLAD168ZOtherMCR
FLG4220OtherBSFL