Provider Demographics
NPI:1043541808
Name:RAY, KELLI M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:M
Last Name:RAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KELLI
Other - Middle Name:M
Other - Last Name:FREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:NE
Mailing Address - Zip Code:68620-0151
Mailing Address - Country:US
Mailing Address - Phone:402-395-5013
Mailing Address - Fax:402-395-2327
Practice Address - Street 1:1019 S 8TH ST
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:NE
Practice Address - Zip Code:68620-1760
Practice Address - Country:US
Practice Address - Phone:402-395-5013
Practice Address - Fax:402-395-2327
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE092612001Medicare PIN