Healthcare Provider Details

I. General information

NPI: 1194761106
Provider Name (Legal Business Name): TEENA PATTY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1549 BELLEMEADE DR
MAYFIELD KY
42066-3723
US

IV. Provider business mailing address

1549 BELLEMEADE DR
MAYFIELD KY
42066-3723
US

V. Phone/Fax

Practice location:
  • Phone: 270-251-0079
  • Fax: 270-251-0079
Mailing address:
  • Phone: 270-251-0079
  • Fax: 270-251-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1091722
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR26522
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: