Provider Demographics
NPI:1497069603
Name:VERNON, FARRAH RAE (DO)
Entity Type:Individual
Prefix:DR
First Name:FARRAH
Middle Name:RAE
Last Name:VERNON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HOSPITAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1649
Mailing Address - Country:US
Mailing Address - Phone:731-352-7907
Mailing Address - Fax:731-352-4459
Practice Address - Street 1:136 S WILSON ST
Practice Address - Street 2:
Practice Address - City:DRESDEN
Practice Address - State:TN
Practice Address - Zip Code:38225-1133
Practice Address - Country:US
Practice Address - Phone:731-364-4900
Practice Address - Fax:731-352-4459
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012004806207Q00000X
TNDO000000517207Q00000X
KY05202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY05202OtherKY LICENSE
TN3380640OtherMEDICARE GROUP
TN3380640OtherMEDICAID GROUP