Provider Demographics
NPI:1760425409
Name:GREEN, PENNY M (CRNA)
Entity Type:Individual
Prefix:MS
First Name:PENNY
Middle Name:M
Last Name:GREEN
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:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37349-0299
Mailing Address - Country:US
Mailing Address - Phone:931-728-5607
Mailing Address - Fax:931-728-8354
Practice Address - Street 1:725 S JAMES CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-5962
Practice Address - Country:US
Practice Address - Phone:931-728-5607
Practice Address - Fax:931-728-8354
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11236367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3627696Medicaid
TN3627699Medicaid
TN4027418OtherBLUECROSS
TN3627699Medicaid