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NPI Code Detail

MEDICARE: PHYLLIS A PEMBERTON CRNA

MEDICARE: PHYLLIS A PEMBERTON CRNA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1367500000XCertified Registered Nurse Anesthetist1017898AL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
151050952OTHERALBLUE CROSS PROVIDER NUMBE

General Provider Information

NPI Number : 1588684344
Entity Type Code : Individual
Provider Name (Legal Business Name) : PHYLLIS A PEMBERTON CRNA
Provider Business Mailing Address
First Line : 1416 RIVER OAKS DR
Second Line :
City : JACKSONS GAP
State : AL
Zip : 36861-3126
Country : US
Telephone Number : 256-825-1456
Fax Number :
Provider Business Practice Location Address
First Line : 3316 HIGHWAY 280
Second Line :
City : ALEXANDER CITY
State : AL
Zip : 35010-3369
Country : US
Telephone Number : 256-329-7120
Fax Number : 256-329-7600
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/21/2006
Last Update Date : 07/09/2007

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Directions to “ PHYLLIS A PEMBERTON CRNA” Practice Location

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