Provider Demographics
NPI:1144229717
Name:BACHUS, PHYLLIS (CRNA)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:BACHUS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 29TH AVE N
Mailing Address - Street 2:STE 202
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 29TH AVE N
Practice Address - Street 2:STE 202
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1401
Practice Address - Country:US
Practice Address - Phone:615-327-4304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN038992367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3605882Medicaid
KY74389925Medicaid
TN3057201OtherBCBS NUMBER
TN3605884Medicare ID - Type Unspecified