Provider Demographics
NPI:1457357162
Name:BECKHAM, PENNY (CRNA)
Entity Type:Individual
Prefix:MS
First Name:PENNY
Middle Name:
Last Name:BECKHAM
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 1:262 DANNY THOMAS PL
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-3678
Mailing Address - Country:US
Mailing Address - Phone:901-595-3006
Mailing Address - Fax:901-595-3842
Practice Address - Street 1:262 DANNY THOMAS PLACE, MS 0515
Practice Address - Street 2:C/O DANA CANNON
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-3678
Practice Address - Country:US
Practice Address - Phone:901-595-3006
Practice Address - Fax:901-595-3842
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN75933367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010016771Medicaid
TX167251101Medicaid
OH2413427Medicaid
IN200456220AMedicaid
ME422400000Medicaid
MO915357800Medicaid
TN3495434Medicaid
SCQRN/APN014Medicaid
MS00126561Medicaid
AR148279701Medicaid
MI104694240Medicaid
OK100849790AMedicaid
LA1132730Medicaid