Provider Demographics
NPI:1699720532
Name:FARRY JENNINGS, LISA (CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FARRY JENNINGS
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:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:13737 NOEL RD
Practice Address - Street 2:STE 1400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28160032367500000X
TX790893367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX215319901Medicaid
TX8645UAOtherBCBS
VA011251A26OtherMEDICARE ID
TX215319902Medicaid
VA011251A26Medicare PIN
IN200335720Medicare ID - Type Unspecified
INCB9080TMedicare ID - Type Unspecified
VA011251A26OtherMEDICARE ID
TX215319902Medicaid
VAP00369083Medicare PIN