Provider Demographics
NPI:1275805699
Name:RAY, GWENDOLYN SUE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:SUE
Last Name:RAY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:GWENDOLYN
Other - Middle Name:SUE
Other - Last Name:FEESER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:266 MAIN ST
Mailing Address - Street 2:P.O.BOX 116
Mailing Address - City:PORT WILLIAM
Mailing Address - State:OH
Mailing Address - Zip Code:45164-1004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:266 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT WILLIAM
Practice Address - State:OH
Practice Address - Zip Code:45164-1004
Practice Address - Country:US
Practice Address - Phone:937-218-1069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH145212164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2900141Medicaid