Provider Demographics
NPI:1598732000
Name:ROOSE, JOY (CRNA)
Entity Type:Individual
Prefix:
First Name:JOY
Middle Name:
Last Name:ROOSE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MEDICAL VILLAGE DRIVE
Mailing Address - Street 2:#258
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017
Mailing Address - Country:US
Mailing Address - Phone:859-341-7246
Mailing Address - Fax:859-341-7867
Practice Address - Street 1:ONE MEDICAL VILLAGE DRIVE
Practice Address - Street 2:INDEPENDENT ANESTHESIOLOGIST PSC
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-341-7246
Practice Address - Fax:859-341-7867
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1076053367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200417780Medicaid
OH0933128Medicaid
000000288568OtherANTHEM BLUE SHIELD
611077369OtherTAX ID
KY74439092Medicaid
IN200417780Medicaid
KY74439092Medicaid
430032128Medicare PIN
M400030354Medicare PIN