Provider Demographics
NPI:1396788923
Name:METHVIN, SUSAN MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:METHVIN
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 440013
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0013
Mailing Address - Country:US
Mailing Address - Phone:615-620-2320
Mailing Address - Fax:615-620-2323
Practice Address - Street 1:1607 N LOCUST AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-2213
Practice Address - Country:US
Practice Address - Phone:931-762-6571
Practice Address - Fax:615-620-2323
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRN1-044989163W00000X
ALAPN1-044989367500000X
TNRN1193101163W00000X
TNAPN09255367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3626663Medicaid
TN4064942OtherBC/BS TN - STAA
TN01036208OtherAMERIGROUP TENNCARE - STAA PAR
TN3626668Medicare PIN