Provider Demographics
NPI:1679645709
Name:BAKER, SALLY JO (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:JO
Last Name:BAKER
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:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-0515
Mailing Address - Country:US
Mailing Address - Phone:304-736-6126
Mailing Address - Fax:304-736-1531
Practice Address - Street 1:2900 FIRST AVENUE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-526-1031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV43588367500000X
OH04994367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV55-0696369-00OtherWV WORKERS COMP #
WV001710226OtherW.V. BLUE CROSS PROVIDER
WV0068000000Medicaid
WV001710226OtherW.V. BLUE CROSS PROVIDER
OH8236331Medicare PIN