Provider Demographics
NPI:1194149385
Name:PEVAHOUSE, WENDY BURKS (APN)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:BURKS
Last Name:PEVAHOUSE
Suffix:
Gender:
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE GI CREDENTIALING DEPARTMENT
Mailing Address - Street 2:PO BOX 381468
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-1468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27A MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3949
Practice Address - Country:US
Practice Address - Phone:731-280-0157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18424363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ009893Medicaid