Basic Information
| Provider Information | |||||||||
| NPI: | 1760754907 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN ALSTINE | ||||||||
| FirstName: | KIMBERLEY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 SPRING FOREST RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276162880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198739533 | ||||||||
| FaxNumber: | 8444540171 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 SAM PERRY BLVD | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224014453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407417614 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2012 | ||||||||
| LastUpdateDate: | 05/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 0024169898 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | VA | MEDICAID |