Provider Demographics
NPI:1053397414
Name:WALECKA, KIM ELLEN I (CRNA)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:ELLEN
Last Name:WALECKA
Suffix:I
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:ELLEN
Other - Last Name:DEROSSI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:228 OLD WESTPORT RD
Mailing Address - Street 2:
Mailing Address - City:DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-2353
Mailing Address - Country:US
Mailing Address - Phone:774-202-5729
Mailing Address - Fax:508-648-1571
Practice Address - Street 1:228 OLD WESTPORT RD
Practice Address - Street 2:
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-2353
Practice Address - Country:US
Practice Address - Phone:774-202-5729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216893367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANA0974Medicare ID - Type Unspecified
MAP63013Medicare UPIN