MEDICARE: MRS. MERRY LYNN GREEN CRNA

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	1023194	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1106570	OTHER	KY	PASSPORT
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2746310000	OTHER	KY	PASSPORT ADVANTAGE

General Provider Information

NPI Number	:	1184703688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MERRY LYNN GREEN CRNA

Provider Business Mailing Address
First Line	:	PO BOX 265
Second Line	:
City	:	CANEYVILLE
State	:	KY
Zip	:	42721-0265
Country	:	US
Telephone Number	:	270-879-8924
Fax Number	:

Provider Business Practice Location Address
First Line	:	904 WALLACE AVE
Second Line	:
City	:	LEITCHFIELD
State	:	KY
Zip	:	42754-1418
Country	:	US
Telephone Number	:	270-259-9470
Fax Number	:	270-259-1662

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

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	10/22/2007

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