Provider Demographics
NPI:1962599563
Name:PENNELL, HEATHER W (CRNA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:W
Last Name:PENNELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:M
Other - Last Name:WOODEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1010 LODGE HILL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5509
Mailing Address - Country:US
Mailing Address - Phone:502-648-2230
Mailing Address - Fax:502-244-4967
Practice Address - Street 1:1 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1318
Practice Address - Country:US
Practice Address - Phone:502-636-7160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3979A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74005968Medicaid
KY74005968Medicaid