Provider Demographics
NPI:1366510448
Name:REDMAN, KIMBERLY L (CRNA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:REDMAN
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1605 MARTIN SPRINGS DR
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2931
Practice Address - Country:US
Practice Address - Phone:417-533-6010
Practice Address - Fax:417-533-6173
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001004539363A00000X
MO2010034566367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
431560263OtherTRICARE
MO1366510448Medicaid
970019029OtherRAILROAD MEDICARE
MOP33030Medicare UPIN
970019029OtherRAILROAD MEDICARE