Provider Demographics
NPI:1194761106
Name:PATTY, TEENA (CRNA)
Entity type:Individual
Prefix:
First Name:TEENA
Middle Name:
Last Name:PATTY
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 1:1549 BELLEMEADE DR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-3723
Mailing Address - Country:US
Mailing Address - Phone:270-251-0079
Mailing Address - Fax:270-251-0079
Practice Address - Street 1:1549 BELLEMEADE DR
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-3723
Practice Address - Country:US
Practice Address - Phone:270-251-0079
Practice Address - Fax:270-251-0079
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1091722367500000X
ARR26522367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74001298Medicaid
KY74001298Medicaid