Provider Demographics
NPI:1669574786
Name:BAILEY, M JUDY (CRNA)
Entity type:Individual
Prefix:
First Name:M
Middle Name:JUDY
Last Name:BAILEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:JUDY
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:118 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 S FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101-2010
Practice Address - Country:US
Practice Address - Phone:717-782-5470
Practice Address - Fax:717-782-5820
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN223850L163W00000X
PARN-223850-L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA430058228Medicaid
CC9810OtherRR GROUP #
1436506OtherBLUE SHIELD
CC9810OtherRR GROUP #