Healthcare Provider Details

I. General information

NPI: 1043441652
Provider Name (Legal Business Name): MARY M PENA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 WALNUT GROVE RD
MEMPHIS TN
38120-2113
US

IV. Provider business mailing address

300 MAIN ST
LEWISTON ME
04240-7027
US

V. Phone/Fax

Practice location:
  • Phone: 901-226-5000
  • Fax:
Mailing address:
  • Phone: 901-682-2872
  • Fax: 901-682-9316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA183034
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN157932
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number15607
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: