Provider Demographics
NPI:1336179373
Name:MARBLE, CHERYL ANN (CRNA)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
Last Name:MARBLE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:ANN
Other - Last Name:DUNAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:504 CLINTON CENTER DR STE 4300
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5610
Mailing Address - Country:US
Mailing Address - Phone:601-815-2005
Mailing Address - Fax:601-815-0434
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:601-815-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR844765367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02975011OtherMS MEDICAID
MS02975011OtherMS MEDICAID