Basic Information
| Provider Information | |||||||||
| NPI: | 1396788923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | METHVIN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 440013 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372440013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156202320 | ||||||||
| FaxNumber: | 6156202323 | ||||||||
| Practice Location | |||||||||
| Address1: | 1607 N LOCUST AVE | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384642213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317626571 | ||||||||
| FaxNumber: | 6156202323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 08/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN1-044989 | AL | N | Nursing Service Providers | Registered Nurse | 367500000X | APN1-044989 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | RN1193101 | TN | N | Nursing Service Providers | Registered Nurse | 367500000X | APN09255 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3626663 | 05 | TN | MEDICAID | 4064942 | 01 | TN | BC/BS TN - STAA | OTHER | 01036208 | 01 | TN | AMERIGROUP TENNCARE - STAA PAR | OTHER |