Provider Demographics
NPI:1417913989
Name:WILL, KENNETH LAMAR (CRNA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LAMAR
Last Name:WILL
Suffix:
Gender:M
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 SOUTH LOCUST AVENUE
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464
Practice Address - Country:US
Practice Address - Phone:615-620-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC000125367500000X
AL1-063395367500000X
ALRN1-063395163W00000X
FLRN799782163W00000X
TNRN44231163W00000X
TNAPN08946367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406122500Medicaid
TN01069642OtherAMERIGROUP TENNCARE ONLY
TN3632860Medicaid
TN4064894OtherBLUE CROSS/BLUE SHIELD OF TN
MD360LJ044Medicare PIN
TN3632860Medicaid