Provider Demographics
NPI:1174780688
Name:SALLEY, RUBY LOUISE (RN)
Entity type:Individual
Prefix:MRS
First Name:RUBY
Middle Name:LOUISE
Last Name:SALLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:RUBY
Other - Middle Name:LOUISE
Other - Last Name:LA BARRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29 ROGERS LANE
Mailing Address - Street 2:
Mailing Address - City:KEESEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12944
Mailing Address - Country:US
Mailing Address - Phone:518-834-6050
Mailing Address - Fax:
Practice Address - Street 1:300 CHAZY LAKE RD
Practice Address - Street 2:
Practice Address - City:SARANAC
Practice Address - State:NY
Practice Address - Zip Code:12981
Practice Address - Country:US
Practice Address - Phone:518-293-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3804691163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMA01258593Medicaid