MEDICARE: MRS. MARILYN JANE HARROLD C.R.N.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	12-20734-012	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	144858	OTHER	KS	BLUE SHIELD

General Provider Information

NPI Number	:	1063476380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARILYN JANE HARROLD C.R.N.A.

Provider Business Mailing Address
First Line	:	2314 ROSEWOOD AVE.
Second Line	:
City	:	NORTH NEWTON
State	:	KS
Zip	:	67117-0176
Country	:	US
Telephone Number	:	316-282-4847
Fax Number	:

Provider Business Practice Location Address
First Line	:	2314 ROSEWOOD AVE.
Second Line	:
City	:	NORTH NEWTON
State	:	KS
Zip	:	67117-0176
Country	:	US
Telephone Number	:	316-282-4847
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	07/08/2007

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