Provider Demographics
NPI:1629041926
Name:PETHEL, REGINA R (CRNA)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:R
Last Name:PETHEL
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 1:341 TRANE DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-6053
Mailing Address - Country:US
Mailing Address - Phone:865-588-0880
Mailing Address - Fax:
Practice Address - Street 1:1924 ALCOA HWY
Practice Address - Street 2:BOX U109
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1511
Practice Address - Country:US
Practice Address - Phone:865-544-9220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN97058163W00000X
TN049477367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN049477OtherCRNA LICENSE
TNRN 97058OtherRN LICENSE
TNAPN10831OtherADVANCE PRACTICE NURSE
TNAPN10831OtherADVANCE PRACTICE NURSE