Provider Demographics
NPI:1770758450
Name:PEMBROKE, KRISTEN K (CRNA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:K
Last Name:PEMBROKE
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:KAIL
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:877 JEFFERSON AVE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:901-545-7302
Mailing Address - Fax:
Practice Address - Street 1:877 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2807
Practice Address - Country:US
Practice Address - Phone:901-448-5893
Practice Address - Fax:901-448-5540
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901380367500000X
TNAPN13511367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1505838Medicaid
TN1505838Medicaid