Provider Demographics
NPI:1396727087
Name:MARSHALL RAY, SANDY LEEANN (CRNA)
Entity type:Individual
Prefix:
First Name:SANDY
Middle Name:LEEANN
Last Name:MARSHALL RAY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SANDY
Other - Middle Name:LEEANN
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30133-1950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8954 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2272
Practice Address - Country:US
Practice Address - Phone:770-920-6413
Practice Address - Fax:678-838-2532
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN150781367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000903548BMedicaid
GA491431789AMedicaid
GAGRP6182Medicare PIN
GA43BBBBDMedicare PIN
GA491431789AMedicaid