Provider Demographics
NPI:1548896897
Name:DUBOSE, RUBY (CNA)
Entity type:Individual
Prefix:MRS
First Name:RUBY
Middle Name:
Last Name:DUBOSE
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1238
Mailing Address - Country:US
Mailing Address - Phone:662-655-0105
Mailing Address - Fax:
Practice Address - Street 1:1723 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1238
Practice Address - Country:US
Practice Address - Phone:662-655-0105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1165308374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide