Provider Demographics
NPI:1346219011
Name:BOHANNON, BETTY (CRNA)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:BOHANNON
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 1:144 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:COPPERHILL
Mailing Address - State:TN
Mailing Address - Zip Code:37317-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 29TH AVE N
Practice Address - Street 2:
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?:No
Enumeration Date:2006-03-15
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47514367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN620931432OtherTRICARE REGION SOUTH
TN4112892OtherBCBS
KY74009796Medicaid
TN3625345Medicaid
AL009933759Medicaid
TN620931432OtherTRICARE REGION SOUTH
KY74009796Medicaid