Provider Demographics
NPI:1336144013
Name:RUBY-CANADAY, MARLENE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MARLENE
Middle Name:
Last Name:RUBY-CANADAY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:MARLENE
Other - Middle Name:
Other - Last Name:BERGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:639 N MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-1931
Mailing Address - Country:US
Mailing Address - Phone:270-737-4600
Mailing Address - Fax:270-737-1722
Practice Address - Street 1:639 N MULBERRY ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1931
Practice Address - Country:US
Practice Address - Phone:270-737-4600
Practice Address - Fax:270-737-1722
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48317367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74253006Medicaid
0336320Medicare ID - Type Unspecified
KY74253006Medicaid