Provider Demographics
NPI:1083245682
Name:RAY, LEE ANN
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
Last Name:RAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 WHITE CAP WAY
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5306
Mailing Address - Country:US
Mailing Address - Phone:321-626-2805
Mailing Address - Fax:
Practice Address - Street 1:1438 WHITE CAP WAY
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5306
Practice Address - Country:US
Practice Address - Phone:321-626-2805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-01
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103600100Medicaid