Basic Information
Provider Information
NPI: 1417913989
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WILL
FirstName: KENNETH
MiddleName: LAMAR
NamePrefix:  
NameSuffix:  
Credential: CRNA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 440013
Address2:  
City: NASHVILLE
State: TN
PostalCode: 372440013
CountryCode: US
TelephoneNumber: 6156202320
FaxNumber: 6156202323
Practice Location
Address1: 1607 SOUTH LOCUST AVENUE
Address2:  
City: LAWRENCEBURG
State: TN
PostalCode: 38464
CountryCode: US
TelephoneNumber: 6156202320
FaxNumber:  
Other Information
ProviderEnumerationDate: 04/25/2006
LastUpdateDate: 08/05/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
367500000XAC000125MDN Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 
367500000X1-063395ALN Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 
163W00000XRN1-063395ALN Nursing Service ProvidersRegistered Nurse 
163W00000XRN799782FLN Nursing Service ProvidersRegistered Nurse 
163W00000XRN44231TNN Nursing Service ProvidersRegistered Nurse 
367500000XAPN08946TNY Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

ID Information
IDTypeStateIssuerDescription
40612250005MD MEDICAID
0106964201TNAMERIGROUP TENNCARE ONLYOTHER
363286005TN MEDICAID
406489401TNBLUE CROSS/BLUE SHIELD OF TNOTHER


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