Provider Demographics
NPI:1316225642
Name:LUSK, KIMBERLY Y (CRNA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:Y
Last Name:LUSK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:Y
Other - Last Name:DANIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1984 PEACHTREE RD NW
Mailing Address - Street 2:SUITE 515
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-5219
Mailing Address - Country:US
Mailing Address - Phone:404-351-1745
Mailing Address - Fax:404-351-1721
Practice Address - Street 1:1984 PEACHTREE RD NW
Practice Address - Street 2:SUITE 515
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-5219
Practice Address - Country:US
Practice Address - Phone:404-351-1745
Practice Address - Fax:404-351-1721
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN168271367500000X
NC230786390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered