Provider Demographics
NPI:1770829509
Name:RYALS, MARY KELLY (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KELLY
Last Name:RYALS
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 1:165 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6866
Mailing Address - Country:US
Mailing Address - Phone:601-707-7705
Mailing Address - Fax:601-707-7705
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-26
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR877106367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
271785YPC0OtherMEDICARE PTAN