Provider Demographics
NPI:1912087172
Name:KERNODLE, VIRGINIA LEE (CRNA)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:LEE
Last Name:KERNODLE
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 1:3871 PRESCOTT RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-5959
Mailing Address - Country:US
Mailing Address - Phone:901-494-4506
Mailing Address - Fax:
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 905 B
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5202
Practice Address - Country:US
Practice Address - Phone:901-682-2872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN133007367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4144051OtherBLUE CROSS
TN4144051OtherBLUE CROSS