Provider Demographics
NPI:1700830544
Name:FENDLEY, JEREMY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:FENDLEY
Suffix:
Gender:M
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:2006-05-19
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN 10544367500000X
TNRN 147039163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4098869OtherBLUE CROSS
TNP00178338OtherRAILROAD MEDICARE
MS08152327Medicaid
AR161283001Medicaid
AR83990OtherBLUE CROSS
TN3634116Medicaid
TN3634116Medicare ID - Type Unspecified