Provider Demographics
NPI:1588684344
Name:PEMBERTON, PHYLLIS A (CRNA)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:A
Last Name:PEMBERTON
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 1:1416 RIVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONS GAP
Mailing Address - State:AL
Mailing Address - Zip Code:36861-3126
Mailing Address - Country:US
Mailing Address - Phone:256-825-1456
Mailing Address - Fax:
Practice Address - Street 1:3316 HIGHWAY 280
Practice Address - Street 2:
Practice Address - City:ALEXANDER CITY
Practice Address - State:AL
Practice Address - Zip Code:35010-3369
Practice Address - Country:US
Practice Address - Phone:256-329-7120
Practice Address - Fax:256-329-7600
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1017898367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51050952OtherBLUE CROSS PROVIDER NUMBE
AL586848Medicare UPIN