Basic Information
| Provider Information | |||||||||
| NPI: | 1497269799 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARSHALL MEDICAL CENTER SOUTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRNA PROFESSIONAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 227 BRITTANY RD | ||||||||
| Address2: | |||||||||
| City: | GUNTERSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359765766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568946600 | ||||||||
| FaxNumber: | 2568946731 | ||||||||
| Practice Location | |||||||||
| Address1: | 2505 US HIGHWAY 431 | ||||||||
| Address2: | |||||||||
| City: | BOAZ | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359575908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565938310 | ||||||||
| FaxNumber: | 2568403647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2568946701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.