Provider Demographics
NPI:1962465948
Name:CLENDENIN, JOHNNY F JR (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:F
Last Name:CLENDENIN
Suffix:JR
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:PO BOX 1272
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-1272
Mailing Address - Country:US
Mailing Address - Phone:870-535-7457
Mailing Address - Fax:870-535-2522
Practice Address - Street 1:1801 W 40TH AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6900
Practice Address - Country:US
Practice Address - Phone:870-535-7457
Practice Address - Fax:870-535-2522
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC01168367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145162701Medicaid
P00319061OtherRR MCR
AR5U558OtherBCBS
AR145162701Medicaid