Provider Demographics
NPI:1548439623
Name:DUTTLINGER, KIMBERLY JO (RN, CRNA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JO
Last Name:DUTTLINGER
Suffix:
Gender:F
Credentials:RN, CRNA
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:JO
Other - Last Name:BAYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CRNA
Mailing Address - Street 1:925 WEST ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-2757
Mailing Address - Country:US
Mailing Address - Phone:815-223-3300
Mailing Address - Fax:815-224-6763
Practice Address - Street 1:925 WEST ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354
Practice Address - Country:US
Practice Address - Phone:815-223-3300
Practice Address - Fax:815-224-6763
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-22
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006987367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209006987OtherSTATE LICENSE