Provider Demographics
NPI:1447201348
Name:PERNELL, IDA (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:IDA
Middle Name:
Last Name:PERNELL
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 1:1900 EXETER RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2954
Mailing Address - Country:US
Mailing Address - Phone:901-818-2160
Mailing Address - Fax:901-682-9522
Practice Address - Street 1:1900 EXETER RD
Practice Address - Street 2:SUITE 210
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2954
Practice Address - Country:US
Practice Address - Phone:901-818-2160
Practice Address - Fax:901-682-9522
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8954367500000X
TN044684163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3625361Medicaid
TN4011478OtherBLUE CROSS
TN430074179OtherRAILROAD MEDICARE
AR98971OtherBLUE CROSS
MS00126210Medicaid
TN3625362Medicare ID - Type Unspecified