1275805699 NPI number — MRS. GWENDOLYN SUE RAY LPN

Table of content: MRS. GWENDOLYN SUE RAY LPN (NPI 1275805699)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275805699 NPI number — MRS. GWENDOLYN SUE RAY LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAY
Provider First Name:
GWENDOLYN
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FEESER
Provider Other First Name:
GWENDOLYN
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275805699
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
266 MAIN ST
Provider Second Line Business Mailing Address:
P.O.BOX 116
Provider Business Mailing Address City Name:
PORT WILLIAM
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45164-1004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
266 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT WILLIAM
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45164-1004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-218-1069
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  145212 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2900141 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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