Provider Demographics
NPI:1184703688
Name:GREEN, MERRY LYNN (CRNA)
Entity type:Individual
Prefix:MRS
First Name:MERRY
Middle Name:LYNN
Last Name:GREEN
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 265
Mailing Address - Street 2:
Mailing Address - City:CANEYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42721-0265
Mailing Address - Country:US
Mailing Address - Phone:270-879-8924
Mailing Address - Fax:
Practice Address - Street 1:904 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1418
Practice Address - Country:US
Practice Address - Phone:270-259-9470
Practice Address - Fax:270-259-1662
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1023194367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1106570OtherPASSPORT
KY74191438Medicaid
KY2746310000OtherPASSPORT ADVANTAGE
KY74191438Medicaid